Instructor Candidate Application

Instructor Candidate Application

American Heart Association Emergency Cardiovascular Care Programs
Enter Your Access Code*
This is for You, the Instructor Candidate
Instructions: To be completed by the instructor candidate with appropriate signatures. Complete 1 application for each discipline.
Application for Instructor Status: Select the discipline you are applying for (select only 1)*

HeartsaverBLSACLSACLS EPPALSPEARS
Renewal Date of Provider Card*

MonthDayYear
Date
Candidate's Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number
Email*
example@example.com
Instructor Commitment
As an AHA Instructor, I agree to:*

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.
Attach your current Provider Card*

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Attach your Instructor Essentials Certificate*

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Signature of Instructor Candidate*

Clear
Date*

MonthDayYear
Date
TC Only Access Code
This is for the TC, not Instructor Candidates
Verification of Instructor Potential
I verify that this instructor candidate has achieved a score of 84% or higher on the provider written examination in the discipline for which he or she is applying and has completed at least 1 of the following options:*

Has been identified as having instructor potential during performance in a provider course.Has demonstrated instructor potential during a screening evaluation.Has demonstrated exemplary performance of provider skills under my direct observation.
Signature of Training Faculty

Clear
Date

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.
Instructor ID #
Renewal Date

MonthDayYear
Date
TC Name*
TC ID #*
Signature of TC Coordinator

Clear
Date

MonthDayYear
Date
Should be Empty: