Instructor Candidate Application Form printable pdf download

American Heart Association Emergency Cardiovascular Care Program

Instructor Candidate Application

Instructions: To be completed by Instructor candidate with appropriate signatures. Please complete one

application for each discipline.

Name (with credentials):_______________________________________________

Mailing address:_____________________________________________________

___________________________________________________________________

Phone:______________________________ Fax: ___________________________

Email:_____________________________________________________________

Type of Instructor Course:

BLS

ACLS

PALS

Recommended renewal date of Provider card in discipline in which candidate is seeking

Instructor status: ______________

Instructor Commitment: As an AHA Instructor, I agree to teach at least four courses in two years in

accordance with the guidelines of the American Heart Association. I also agree to strengthen and support

the Chain of Survival and the mission of the American Heart Association in my community.

Signature of Instructor Candidate

Date

TC Alignment: I approve this application and grant alignment with this Training Center for this applicant.

I agree to all responsibilities for this Instructor as outlined in this manual.

Name of Training Center: ________________________________________________________

Signature of TC Coordinator: _____________________________________ 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/she is applying and has completed

at least one 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 TCF/Course Director/Lead Instructor (circle appropriate title)

Date

Instructor Candidate Application, Revised March 2004

Instructor Candidate Application Form