All in one form

INSTRUCTOR AFFILIATION AGREEMENT
This agreement is executed between Eyes On Health CPR Services,AHA National Training Center and Enter Name Here* . The Instructor agrees to follow the administrative policies established by the American Heart Association and administered by EOHCPR. These include:
- Providing courses where necessary to meet the training needs
- Submit course notifications to the training center as appropriate (BLS and ACLS)
- Submit course rosters within 20 days of course completion
- Conduct all courses in accordance with AHA Policy
- Utilize appropriate AHA text and instructional materials
- Decontaminate manikins in accordance with manufacturers instructions
- Attend annual updates
- Teach the required minimum number of courses (4 classes over 2 years)
- Be monitored in at least on course annually
Eyes On Health CPR Services will provide administrative services that will include:
- Processing course rosters
- Issuing ecards in a timely manner, 20 day max time frame
- Monitoring of instructor activities and reporting activity to Regional and National Affiliates
- Provide Update information
- Serve as a liaison to the National and Southeast Region of the American
- Heart Association from EOHCPR Training Center
I do hereby agree to follow the requirements of the American Heart Association and the EOHCPR Training Center
If you miss your renewal date, you will lose all inventory and it will not be replaced. Additionally, you will be removed from the system by the American Heart Association (AHA) and will no longer be recognized as an active provider until renewal is completed.*

I understand and agree to the statement above
Please indicate your level(s) of certification:*

BLSHeartsaverACLS
Instructor Signature: Signature* Date: Date*

Instructor Candidate Application
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):
Renewal date of provider card:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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
Signature of Instructor Candidate: Signature* Date: Date*
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 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: Elaine Wiggins
Date: (Course Director Only)
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.
TC Name: TC ID #: GA50566

Signature of TC Coordinator: E. Wiggins
Date: Date (Course Director Only)

Renewing Discipline:*

HeartsaverBLSACLSPEARS
American Heart Association Emergency Cardiovascular Care Programs

Instructor/Training Center Faculty Renewal Checklist
Instructions: This checklist may be used to document successful completion of instructor/Training Center Faculty (TCF) renewal requirements and contact information. It is recommended that the TC keep the completed form in the instructor’s file.

Complete 1 form per renewing discipline.

To be used in conjunction with the Instructor Monitoring Tool.

SECTION 1: General information for the renewing instructor or TCF member.
Renewing discipline:    Heartsaver   BLS   ACLS   PEARS
Expiration date of instructor card:
Primary TC name:   Eyes on Health CPR
TC ID #:  GA-50566
TC Coordinator’s name: Elaine Wiggins
Instructor ID#:
Instructor’s name: *

First NameLast Name
Email*
example@example.com
Mailing address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

	Course Name	Date	Location
x
x
x
x

	Course Name	Date	Location
x
x

INSTRUCTOR AFFILIATION AGREEMENT

Instructor Candidate Application

American Heart Association Emergency Cardiovascular Care Programs