Outside Student
HeartSaver AED Registration Form 

 

Date to Attend

Last Name
First Name
Middle Initial
Address
City
State
Zip Code
Phone Number
Alternate Phone Number
Employer
E-mail Address
Last Four of Your Social Security Number
Month and Day of your Birthday (MM/DD)
Fee for Course     $30  
Method of Payment
       
  

If payment will be made by check, please mail to:

Department of Life Support Education
Wake Forest Baptist Medical Center
Medical Center Boulevard
Winston-Salem, NC 27157

If paying in cash or credit card, please deliver in person to the Department of Life Support Education-3rd floor South Building.
 
Comments/Concerns  
We will notify you of your acceptance into the class through the e-mail 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

3rd Floor South Building
Find a Doctor Ways to Give
USNWR 2013-2014Magnet Hospital RecognitionConsumer Choice2014 Best DoctorsJoint Commission Report

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.