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American
American
Heart I Stroke
Association
Association
,
life is why·
American Heart Association Emergency Cardiovascular Care Programs
Instructor Candidate Application
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
®
Renewal date of provider card:
Candidate’s name:
Mailing address:
City: State: 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.
Instructor ID #: Renewal Date:
TC Name: TC ID #:
Signature of TC Coordinator: __________________________________ Date: _______________
Instructor Candidate Application Revised: January 2018
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