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ACLS Provider Registration Form

This two-day course is designed for participants who have never taken ACLS or for providers who don’t practice the concepts frequently.


The Wake Forest School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians and designates this live activity for a maximum of 11.0 AMA PRA Category 1 Credit(s)TM.

Wake Forest Baptist Medical Center Nursing Education is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Participation in this class provides 11.0 CEUs.


Outside Students:  $300 (MD, PA) $150 (RN, EMT-P, etc.)

*Refunds will not be given if you are unable to attend this class. Please do not pay for a class unless you are prepared to attend the class date that you have scheduled. If unable to attend your scheduled date, we will gladly move you to a different day that will work with your schedule.

Employees: No Charge

Class Time: Day 1--8am til 5pm  and  Day 2--8am til 3pm 
NOTE:  Participants must have a current AHA BLS Provider card (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 Employee?  
If YES, are you a Cornerstone, Wilkes Regional, School of Medicine,
NCBH, Community Physicians Employee, or Travel Nurse?
If NO, place of Employment?
Date to Attend   
Last Name
First Name
Middle Initial
Employee ID
Credentials (MD, RN, etc)
City and State
Zip Code
Phone Number
E-mail Address
If an Employee, Manager's Name / Department
Method of Payment:

MD/PA-$300.00 w/student manual

NP/RN/EMT-P/etc.-$150.00 w/student manual
If payment will be 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, please deliver in person to the Department of Life Support Education on the 3rd floor South Building.   
If paying by credit card, please call 336-716-2800 or stop by Life Support Education.    

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

To access the pre-course assessment, go to and enter this code: acls15.

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
Kathy Nelson

Phone 336-716-2005
Fax 336-716-5927

Contact Kathy

Mikell White
Education Systems Specialist

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

Contact Mikell


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.

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