AHA Instructor Candidate Application

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Course Disciplines

AHA BLS Instructor Essentials

AHA ACLS Instructor Essentials

AHA PALS Instructor Essentials

Session Information

Course Discipline *

Candidate Information

First name *

Last name *

Email *

It is suggested that you use an email address that can be permanently accessed, i.e, a personal email address.

Confirm the previous field *

Mobile Phone *

Street Address *

City *

State *

Zip Code *

EMS Affiliation

Are you an EMS Provider? *

(First Responder, ECP, EMR, EMT, AEMT, Intermediate EMT, Paramedic)

Certification Level *

Choose your current certification level. If your certification is not listed or you are not certified as a healthcare provider, select the "Other" option. If you are not certified please enter "N/A" in the Other field.

EMS Region *

County *

County where you perform your primary EMS duties

EMSP License Number

AHA Instructor Information

Complete this section if you are currently an AHA instructor in other disciplines or if you already have an established AHA Instructor ID number.

Are you currently certified as an AHA Instructor in a separate discipline? *

Do you already have an established AHA Instructor ID Number? *

This only applys to current and former AHA instructors.

AHA Instructor ID Number

Enter your AHA Instructor ID # if you have already been assigned one, otherwise leave blank.

ACLS Instructor

ASLS Instructor

BLS Instructor

Heartsaver Instructor

PALS Instructor

PEARS Instructor

Course Pre-requisites

Date of Birth *

AHA requires all instructor candidates to be 18 years of age at the time of course participation.

AHA BLS Provider Expiration Date *

The expiration date on your AHA card shows a month/year. In this field enter the last day of the month indicated on your official AHA certification. If you are not current as an AHA BLS Provider you must obtain your provider certification and provide proof to the BREMSS TC prior to the date of your course.

AHA BLS Provider Certification *

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Upload a current copy of your AHA BLS Provider Certification. If you are not current as an AHA BLS Provider you must obtain your provider certification and provide proof to the BREMSS TC prior to the date of your course.

AHA ACLS Provider Expiration Date *

The expiration date on your AHA card shows a month/year. In this field enter the last day of the month indicated on your official AHA certification. If you are not current as an AHA ACLS Provider you must obtain your provider certification and provide proof to the BREMSS TC prior to the date of your course.

AHA ACLS Provider Certification *

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Upload a current copy of your AHA ACLS Provider Certification. If you are not current as an AHA ACLS Provider you must obtain your provider certification and provide proof to the BREMSS TC prior to the date of your course.

AHA PALS Provider Expiration Date *

The expiration date on your AHA card shows a month/year. In this field enter the last day of the month indicated on your official AHA certification. If you are not current as an AHA PALS Provider you must obtain your provider certification and provide proof to the BREMSS TC prior to the date of your course.

AHA PALS Provider Certification *

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Upload a current copy of your AHA PALS Provider Certification. If you are not current as an AHA PALS Provider you must obtain your provider certification and provide proof to the BREMSS TC prior to the date of your course.

Verification of Instructor Potential or Employer/Agency Letter of Recommendation *

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Candidates must provide either verification of instructor potential or a letter from your employer or agency requesting admission to the AHA Instructor Essentials Course and verifying that you meet the prerequisite skills and knowledge pertaining to the requested discipline. A letter from the AHA lead instructor from the candidates most recent provider course verifying instructor potential may be used to meet this requirement. This must be received by the BREMSS Training Center prior to processing of this application.

Instructor Commitment: As an AHA Instructor, I agree to

All statements must be accepted to continue the application process.

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 *

Consent to electronic signature *

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Electronic Signature of instructor candidate *

By signing this form, I attest that all information submitted is true and accurate to the best of my knowledge. Falsification of any of the above information will result in dismissal from the course as well as revocation of any other certifications aligned with the BREMSS Training Center.

Today's Date *

Important information

*Completion of this application does not guarantee acceptance into the BREMSS AHA Training Center, nor does it guarantee availability in your desired course or session date. Your session date is not finalized until you have officially been accepted and you have completed the official course registration.

Session Information

Candidate Information

EMS Affiliation

AHA Instructor Information

Company Information

Course Pre-requisites

Instructor Commitment: As an AHA Instructor, I agree to

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