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Instructor Support Application

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* Required information.
First Name * As it appears on instructor card(s)
Last Name * As it appears on instructor card(s)
Street Address * Course completion cards will be sent to this address
Street Address 1
City *
State *
Postal Code *
Contact Phone * Do not include dashes, etc. Use a number you access frequently
Phone Type *
Email * Having an email account is now mandatory for all instructors. Free email services are available online (eg. Gmail) and can be accessed free at any public library. We ask that you check your email at least once per week, to make sure you keep up-to-date with all LHS information. An instructor contract will also be sent to this email for signature.
Email Type *
Professional Credentials * MD, RN, EMT...Enter 'none' if you have none.
Last Four of Social Security Number * Used for payment processing and record tracking only.
Will you need equipment to support your training efforts? Equipment based upon availability, geographical location, and rental agreement terms.
Anticipated number of students you will train each year? A realistic number helps us plan to better support your needs.
If current instructor who is your credentialing organization?
For those seeking instructor status with Love Health Service, which credentialing organization do you seek?
Other
Place of Employment *
Employer Street Address *
Employer City *
Employer State *
Employer Postal Code *
Current Training Center’s Name * Only required for American Heart instructors. Put “none” if question does not apply.
Current Training Center’s Contact Person * Who can verify your alignment with the training center and support your ability to teach well? Only required for American Heart instructors. Put “none” if question does not apply.
Current Training Center’s Street Address * Only required for American Heart instructors. Put “none” if question does not apply.
Current Training Center’s City * Only required for American Heart instructors. Put “none” if question does not apply.
Current Training Center’s State * Only required for American Heart instructors. Put “none” if question does not apply.
Current Training Center’s Postal Code * Only required for American Heart instructors. Put “none” if question does not apply.
Contact me before you contact my current training center *
CPR Instructor Card Expiration Date Required for those wanting CPR support
ACLS Instructor Card Expiration Date Required for those wanting ACLS support
PALS Instructor Card Expiration Date Required for those wanting PALS support
Current CPR Instructor Card 5 megabyte file size limit, a copy of your card will be required for BLS support
Current ACLS Instructor Card Required for ACLS Support. 5 megabyte file size limit.
Current PALS Instructor Card Required for PALS Support. 5 megabyte file size limit.

By submitting this form you digitally are agreeing to:

  • uphold the confidentiality policy of Love Health Service, LLC
  • not share any information about Love Health Service, its clients, instructors, or any other information unless you receive written authorization
  • maintain all instructor related requirements including by not limited to test security, equipment maintenance, and card security

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