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 CURRENT wilderness medicine instructor certification from another organization?*

No, I do not have any other current wilderness medicine instructor certificationsYes, I have a wilderness medicine instructor certification from another training provider (ex: NOLS, Red Cross, ECSI, HSI, etc.)
List your prior or current wilderness medicine INSTRUCTOR credentials. Click "ADD ROW" as needed.*

Other Medical Instructor Credentials &/Or Experience
Do you have any other CURRENT OR PRIOR medical or emergency response INSTRUCTOR experiences and/or certifications? Examples: general first aid, BLS, CPR, ACLS, EMS, or nursing instructor.*

No, I do not have any other current or prior medical/emergency medical response instructor credentials or experienceYes, I have other current or prior medical/emergency medical response instructor credentials or experience
List other MEDICAL INSTRUCTOR experience or credentials related to emergency medical response. Examples: general first aid, BLS, CPR, search & rescue skills. Click "ADD ROW" as needed.*

Non-Medical Instructor or Group Leader Experience
Do you have any other current or prior NON-MEDICAL formal or informal, official or unofficial adult education instructor or group leader experiences in any field? Examples: search & rescue, CERT, disaster management, community college instructor, high school teacher, military leadership, avalanche or lifeguard instruction, etc.*

No, I don't have any other instructor credentials or experienceYes, I have other instructor credentials or experience related to teaching or training adults
List your other NON-MEDICAL instructor or group leader experiences or credentials below. Click "ADD ROW" as needed.*

Your Interests & Experiences
Tell us about your interests and experiences in outdoor, remote, austere and/or wilderness settings. No need to repeat anything you already listed!*
Tell us about your experiences:*
Other Information
Link to your LinkedIn profile if you have one - otherwise, enter NA.*
Link to your Facebook profile if you have one - otherwise, enter NA.*
Link to your Instagram 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*
Should be Empty:

Overview