NORTH GEORGIA TECHNICAL COLLEGE | PO BOX 65 CLARKESVILLE, GA 30523 | CONTED@NORTHGATECH.EDU
NGTC AHA New Instructor Packet
Th
ank you for becoming an AHA Instructor! We can’t wait to have you join our training center! Please use the
following packet to become a new instructor as well as affiliating with our training center.
A few reminders:
Please complete one packet per discipline.
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 new instructor
requirements and contact information.
A packet must be completed for each discipline you are renewing for (i.e. ACLS, BLS, PALS, Heartsaver).
Checklist
Affiliation Requested from North Georgia Tech TC
Completed Instructor Candidate Application
Completed Monitor Form (completed by TCF)
Completed Affiliation Agreement
Class Roster from Instructor Class (completed by TCF)
Copy of Provider Card
Instructor Card Payment of $10
Pl
ease 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
Requesting Affiliation with AHA and North
Georgia Tech TC
Be
coming an American Heart Association instructor is easy after consulting with an AHA Training Center.
If you already have an AHA Instructor Network account, DO NOT create a new account. Log into your current
account and start at “Step 2”
Registering as a New User:
Step 1: Go to AHA Instructor Network website (www.ahainstructornetwork.org)
Click “Register” button.
Complete “Create Account”; add information
Review “User Agreement” section
Click “Continue to Step 2” button
Step 2: Complete “Edit Affiliations” page
1
. S
elect Your Training Center County USA is pre-selected
2
. S
elect Your Primary Training Center for each Discipline
Choose the appropriate Training Center for the correct discipline using the “Lookup” button
3.
S
elect Your Facilitator Disciplines
Click “Continue to Step 3”
Step 3: Register for the AHA Instructor Network confirm your information
At this point the registration process is complete!
Click “Submit Registration” button
O
nce you complete your registration, an email will be sent confirming your registration. When we have
confirmed you as an instructor, you will be sent an email with your confirmation.
American Heart Association Emergency Cardiovascular Care Programs
Instructor Candidate Application
Instructor Candidate Application Revised: March 2019
Instructions: To be completed by the instructor candidate with appropriate signatures. Complete
1 application for each discipline.
Application for Instructor Status: Select the discipline you are applying for (select only 1):
Heartsaver
®
BLS ACLS ACLS EP PALS PEARS
®
State: Zip code:
Renewal date of provider card:
Candidate’s name:
Mailing address:
City:
Phone:
Email:
Instructor Commitment: As an AHA Instructor, I agree to
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 AHA Statement of Conflict
of Interest
Signature of instructor candidate: 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 or she is applying and has
completed at least 1 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 Training Center (TC) Faculty/Course Director:
(circle appropriate title)
Date:
TC Alignment and Instructor Network Verification: TC Coordinator of aligning TC has verified the
following:
I approve this application and grant alignment with this TC for this applicant. I agree to all
responsibilities for this instructor as outlined in the current Program Administration Manual.
I verify that this instructor is registered on the Instructor Network and has been approved as
an instructor in this discipline and is aligned with this TC.
Renewal Date: Instructor ID #:
TC Name: TC ID #:
Signature of TC Coordinator: __________________________________ Date: _______________
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N
ORTH GEORGIA TECHNICAL COLLEGE | PO BOX 65 CLARKESVILLE, GA 30523 | CONTED@NORTHGATECH.EDU
Instructor Agreement Affiliation with
North Georgia Tech TC
First and Last Name:
(please print)
Address:
City: State: Zip:
Cell Phone: Work Phone:
Email Address:
Employer:
Please mark the appropriate disciplines for which you are requesting to become an Instructor in:
BLS
ACLS
PALS
Please include a copy of all current provider cards.
I, , do hereby agree to follow the requirements of AHA and
NGTC in teaching any and all courses affiliated with AHA. This includes using the appropriate
instructor tool kit, providing AHA manuals before, during and after classes to students, and
providing cards after the course is completed; as well as submitting the roster to the TC for
teaching credit. I realize I must teach 4 courses and be monitored in a two-year period and attend
an update in all disciplines I am an instructor in to maintain my current instructor status.
Signature: Date:
CTC Rep: Date:
Submit to: Leslie Foster
conted@northgatech.edu
North Georgia Technical College
AHA Training Center
PO Box 65
Clarkesville, GA 30523
706-754-7715
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signature
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