NEW INSTRUCTOR FORM

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Instructions: To be completed by the instructor candidate with appropriate signatures. Complete 1 application for each discipline.

SECTION 1:

Application for Instructor Status: Select the discipline you are applying for (select only 1)

HeartSaver®

BLS

ACLS

ACLS EP

PALS

PEARS®

Renewal Date of Provider Card:

SECTION 2:

Instructor Commitment: As an AHA Instructor, I agree to the following:

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 AGA Statement of Conflict of Interest

Signature of Instructor Candidate

Thank you for submitting. A member from our staff will be in touch shortly.

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Saturday 9:00 AM - 3:00 PM

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