Instructor Candidates

If you are interested in becoming an instructor, please use the form below to kick off the process by providing the CSRE staff with the pertinent information we need to get you registered.

Personal Information

Your Full Name *

First

Middle

Last

Mailing / Physical Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

How did you come upon our website? (Google, friend, AHA, etc.)

Instructor Aspirations

Select the discipline(s) you are interested in instructing: *

• BLS
• ACLS
• PALS
• Heartsaver
• HSI (ASHI/Medic First Aid)

Do you currently hold a valid Instructor Certification for the discipline(s) you selected above? *

• Yes
• No

Instructor Certification Expiration

To be an Instructor, the prerequisite is that you hold a valid provider card in the discipline(s) which you want to instruct. Do you have a current provider card for the discipline(s) you want to instruct? *

• Yes
• No (Don’t worry, we can assist you with this requirement)

Provider Expiration Date

Help Us Get To Know You

In brief, what relevant healthcare or instructor experience do you have? This field is required, if you have no relevant experience, please enter "None". *

In brief, why are you interested in becoming an instructor? Do you have a timeline or goals you wish to share with us? *

Is there anything else about you that you would like to share with us? This field is not required.

Resume and/or Certification Cards

If you have a current, professional resume, or access to your Instructor or Provider eCards, please upload it here. This is not required.

Click or drag files to this area to upload. You can upload up to 5 files.

PDF or Word Document

Acknowledgement

By entering my email address below, I certify that I have read and understand the prerequisite information and that the information I have provided above is accurate.

I authorize CSRE staff to contact me via the following email or phone.

Email *

Phone *

Submit Application