AHA Instructor Candidate Application

American Heart Association Emergency Cardiovascular Care Programs
Instructor Candidate Application
Instructions: To be completed by the instructor candidate with appropriate signatures. Complete 1 application for each discipline.
HeartsaverBLSACLSACLS EPPALSPEARS
Renewal date of provider card*

MonthDayYear
Date
Candidate’s name*
Mailing address*
City*
State*
Phone*
Email*
example@example.com
Please select the Training Site you are associated with?*
Teach at least 4 courses in 2 years in accordance with the guidelines of the AHAMaintain a current provider cardStrengthen and support the Chain of Survival and the mission of the AHA in my communityConduct myself in accordance with the ECC Leadership Code of ConductAvoid any perception of conflict of interest in accordance with the AHA Statement of Conflict of Interest
Signature of instructor candidate:*

Clear
Date*

MonthDayYear
Date
Upload Supporting Documentation*

Submit a copy of current digital certification card(s) to support your application
Cancelof
Has been identified as having instructor potential during performance in a provider courseHas demonstrated instructor potential during a screening evaluationHas demonstrated exemplary performance of provider skills under my direct observation
Signature of Training Center (TC) Faculty/Course Director:

Clear
Date

MonthDayYear
Date
Name of Training Center (TC) Faculty/Course Director:
I approve this application and grant alignment with this TC for this applicant. I agree to all responsibilities for this instructor as outlined in the current Program Administration Manual.I verify that this instructor is registered on the Instructor Network and has been approved as an instructor in this discipline and is aligned with this TC.
Instructor ID #
Enter your instructor ID found on your instructor certification
Renewal Date

MonthDayYear
Enter the date of expiration on your instructor certification
TC Name
TC ID #
Signature of TC Coordinator

Clear
Date

MonthDayYear
Approval Status
Should be Empty:

American Heart Association Emergency Cardiovascular Care Programs

Instructor Candidate Application