Authorized Instructor Application

Your Contact Details
First Name*
Last Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you a resident of the United States or a U.S. territory?*

Yes, I live in one of the 50 U.S. statesYes, a U.S. territoryNo
Select your U.S. territory*
Select your country*
Street Address 1*
Street Address 2
City*
State*
Zip*
I plan to (select ALL that apply):*

Offer classes on my own, or as part of my own businessOffer classes on behalf of another businessOffer classes as a member of a club or other orgOffer classes to SAR, EMS, fire or other emergency respondersOther - enter here

Prior Wilderness Medicine Instructor Credentials
Do you already have a wilderness medicine instructor certification?*

No, I don't have a prior instructor certificationYes, I have a wilderness medicine instructor certification from another training provider (ex: NOLS, HSI, Base Medical, etc.)

Other Instructor Credentials &/Or Experience
Do you have any other instructor experiences and/or certifications related to medicine or emergency medical response? Examples: general first aid, BLS, CPR, ACLS, EMS, FEMA, CERT, search & rescue or survival skills.*

No, I don't have any other instructor credentials or experienceYes, I have other instructor credentials or experience related to medicine or emergency medical response
List other INSTRUCTOR experience or credentials related to emergency medical response, or "NA" if none. Examples: general first aid, BLS, CPR, ACLS, EMS or other medical subjects, search & rescue or survival skills. CLICK "ADD ROW" for as many rows as needed.*
Other Information
Link to your LinkedIn profile if you have one - otherwise, enter NA.*
OPTIONAL: Is there any other information you want to provide? This is especially helpful if you feel that your qualifications aren't fully represented above.
Please verify that you're human*
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Overview