Heart and Stroke Instructor Application

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In order to register for a Heart and Stroke Instructor program, you must fill out this pre-screening form. Once this has been received we will respond within 24 hours.

Heart and Stroke Instructor Pre-Screening

Instructor Course Requested *
Name:*
Professional Designation *
Date of Instructor Course Requested*	//
	BLS
	ACLS
	PALS
	First AId
Please provide a description of where you will be teaching and how you plan to maintain your instructor status as required by the Heart and Stroke. *
Do you have Monitoring arranged?*
Proof of Provider Certification *
Advanced Inst. Please up load your Practice License*
Do you carry any other Instructor Certifications *
	ACLS
	PALS
	BLS
	First Aid
	ACLS EP
	Other Programs not affiliated with H&S

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