Fillable NGTC AHA Instructor Renewal Packet (North Georgia Technical College)

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NGTC AHA Instructor Renewal Packet (North Georgia Technical College)

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NORTH GEORGIA TECHNICAL COLLEGE | PO BOX 65 CLARKESVILLE, GA 30523 | CONTED@NORTHGATECH.EDU
NGTC AHA Instructor Renewal Packet
Certifications for ALL NGTC Training Center Instructors, regardless of discipline, will expire on June 30
th
of
2021. It is the responsibility of the instructor to ensure that you have met these requirements before June
30, 2021. Failure to complete all these requirements by June 30
th
, 2021 could result in your having to take the
entire instructor course again. These requirements are set by the American Heart Association and they will be
carried out by this training center.
A few reminders:
• Your instructor card will be mailed to the address listed on the form or if you are affiliated with one of our
Training Sites, your card will be sent to the TS Coordinator.
• Card Prices:
o All Heartsaver Cards: $20 ea.
o Health Care Provider Cards (BLS): $7 ea.
o ACLS and PALS: $7 ea.
o All Instructor Cards: $10 ea.
• All course completion cards must be issued within 20 business days of course completion. This time frame is from
the day of course completion to the day the card is released to the individual.
Instructions: This checklist may be used to document successful completion of the instructor renewal
requirements and contact information.
A packet must be completed for each discipline you are renewing for (i.e. ACLS, BLS, PALS, Heartsaver).
Che
cklist
□ Instructor Renewal Form Completed
□ Complete Monitor Form (by TCF)
□ Minimum of 4 Provider Courses taught between July 1, 2019-June 30, 2021.
□ Instructor Card Payment of $10
Ple
ase send forms and money to:
North Georgia Technical College
Attn: AHA Training Center
PO Box 65
Clarkesville, Georgia 30523
NORTH GEORGIA TECHNICAL COLLEGE | PO BOX 65 CLARKESVILLE, GA 30523 | CONTED@NORTHGATECH.EDU
AHA Instructor Renewal Form
First and Last Name:
Phone: Instructor #:
Email Address:
Discipline for which you are requesting re-certification:
□ BLS $10
□ HS $10 □ ACLS $10 □ PALS $10
C
heck one of the following:
□ I have a current AHA Instructor card in the discipline I am requesting re-certification. I am primarily aligned
w
ith NGTC and am not aligned with a Training Site.
I wish to have my instructor card mailed to:
Mailing Address City State Zip
□ I
have a current AHA Instructor card and am primarily aligned with a Training Site that reports to NGTC.
Training Site: TS Coordinator:
TS Mailing Address City State Zip
For Training Center Faculty Only
□
I
am a current TC Faculty member and have taught at least one AHA Instructor/Instructor Renewal Course
within the certification period.
I would like to renew my TC Faculty status for the following discipline:
□ BLS □ HS □ ACLS □ PALS
For Training Center Use Only
Approved For:
□ ACLS Instructor □ ACLS Provider □ BLS Instructor □ BLS Provider □ PALS Instructor □ PALS Provider
Approved By: Date Cards Mailed:
Payment: Cash $ Check $ Check # Credit Card: $ PO #
NORTH GEORGIA TECHNICAL COLLEGE | PO BOX 65 CLARKESVILLE, GA 30523 | CONTED@NORTHGATECH.EDU
Provider Courses
At least 4 provider courses taught in the past 2 years (July 1, 2019-June 30, 2021)
(list classes below; additional classes may be attached or listed on the back of this form)
Course Name Date Location (TC or Site) Station or Module
Assisted Courses
Not required for renewal; for informational purposes only from TC.
Course Name Date Location (TC or Site) Lead Instructor
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NGTC AHA Instructor Renewal Packet (North Georgia Technical College)

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Completed 3 February 2021

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