NCBH/School of Medicine/WFBH Community Physicians Employee
BLS/ACLS Combined Refresher Registration Form

NOTE:
Participants must present a copy of their expiring ACLS card. In order to attend a refresher class, you must have taken ACLS within the last five years. If class taken outside Life Support Education, fax a copy of the card to 336-716-5927 with note stating which class you registered for.

 

Are you an NCBH, School of Medicine, or
WFBH Community Physicians Employee

*Note to ALL School of Medicine/Health Sciences
 and WFBH Community Physicians Employees:
Please send a signed and completed authorization form to Life Support Education
BEFORE the scheduled day of class. This form must be completed by the
administrative person in your area and allows us to bill your department for the course.
This is a requirement to attend class. You can find this form on the
Life Support Education website under FORMS.
 
Date to Attend    
Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, etc)
Phone Number
Alternate Phone Number
Department Name
Department Number
E-mail Address
Re-Enter E-Mail Address
   

By choosing “yes,” I understand that I must complete the ACLS precourse assessment, score at least an 80%, print the results, and bring it with me to class. 

To access the precourse assessment, go to www.heart.org/eccstudent and enter this code: compression. 

I understand that if I do not bring the certificate with me, I will not be allowed to take the class.

                 YES, I have read the above statement.

   
Comments/Concerns  
We will notify you of your acceptance into the class through the email address you provided.

Quick Reference

Life Support Education
Tiffany Loggins
For BLS, ACLS, & ITLS Questions

Phone 336-716-2800
Fax 336-716-5927

Contact Tiffany
tloggins@wakehealth.edu

Jill Pettit
For PALS, NRP, ENPC, TNCC, PITLS, & E-Learning Questions

Phone 336-716-2888
Fax 336-716-5927

Contact Jill
jpettit@wakehealth.edu

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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.