Outside Student
PALS Refresher Registration Form 

Participants must have a current AHA BLS HealthCare Provider card and a copy of their expiring PALS card. In order to attend a refresher class, you must have taken PALS within the last five years. If classes were taken outside Life Support Education, fax a copy of the cards to 336-716-5927 with a note stating which class you registered for.


Date to Attend
Last Name
First Name
Middle Initial
Credentials (MD, RN, etc)
Zip Code
Phone Number
Alternate Phone Number
E-mail Address
Last Four of Your Social Security Number
Month and Day of Your Birthday (MM/DD)
Fee for Course
Method of Payment:

*If paying by check, please address to:
Department of Life Support Education
Wake Forest Baptist Medical Center
Medical Center Boulevard
Winston-Salem, NC 27157

*If paying in cash, please deliver in person to the Department of Life Support Education-3rd floor South Building.

*If paying by credit card, you may pay on the day of class. Please plan to arrive 10 minutes early.


By choosing “yes,” I understand that I must complete the PALS 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: palsprovider.

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.

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

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

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

Contact Jill

3rd Floor South Building
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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.