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Instructor Information
Instructor Number
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Enter Your Full Name
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Location of Training to be Held
Course Location
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Type of Course to be Taught
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HeartSaver CPR Only
HeartSaver First Aid Only
HeartSaver CPR/First Aid Combo
HeartSaver Pediatric CPR/First Aid
HeartSaver Skills Check
Basic Life Support (BLS)
Basic Life Support (BLS) Skills Check
ACLS
ACLS Skills Check
PALS
PALS Skills Check
PEARS
PEARS Skills Check
ASHI CPR/First Aid
ASHI CPR/First Aid
Address
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City
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State
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Zip Code
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Course Date
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Class Start Time
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HH
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MM
Acknowledgement
I agree to the following:
I understand that the TC or AHA may send a representative to my class to monitor. I understand that it is my responsibility as a AHA instructor to ensure all the guidelines are met as outlined in the most updated version of the PAM, instructor manual and TC policy and procedure manual.
I acknowledge and agree with the above statement
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