Instructor Candidate Application

American Heart Association Emergency Cardiovascular Care Programs
Instructor Candidate Application

Revised: November 2018
Instructions: To be completed by the instructor candidate with appropriate signatures. Complete 1 application for each discipline.
Who are you?

Instructor Commitment
AHA Instructor Commitments
- Teach at least 4 courses in 2 years in accordance with the guidelines of the AHA
- Maintain a current provider card
- Strengthen and support the Chain of Survival and the mission of the AHA in my community
- Conduct myself in accordance with the ECC Leadership Code of Conduct
- Avoid any perception of conflict of interest in accordance with the AHA Statement of Conflict of Interest
Instructor Agreement
As an AHA Instructor do you agree to the Instructor Commitments listed above?
Instructor Agreement (Multi-Select)

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 (Instructor Candidate)*

MonthDayYear
Date

TC Alignment and Instructor Network Verification
TC Coordinator of aligning TC has verified the following

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.
IC Application Acceptance
Grant Alignment
Acceptance of Responsibilities
Instructor ID #
Renewal Date

MonthDayYear
Date
Instructor eCode
AHA Instructor Certification eCode #
TCC Name

First NameLast Name
TC ID #
Signature of TC Coordinator

Clear
Date (TCC)

MonthDayYear
Date
Should be Empty:

American Heart Association Emergency Cardiovascular Care Programs