HK Emergency Care and Aquatics Education Instructor Application
(All fields are required)

Please be sure you are affiliated with a training center prior to submitting this application.
1) Application for: New Instructor Reciprocal Certification Renewal
 
2) Courses that you will be teaching (check all that apply):
CPR/AED (ASEP)
Basic First Aid
Complete Emergency Care (CPR/AED, First Aid, Bloodborne Pathogens and Emergency Oxygen in one course)
CPR/AED for Coaches
StarGuard
Starfish Swim Instructor
3) Instructor Candidate Information:
First Name:   Last Name:
         Email:
Organization Name:
Address1:
Address2:
City:                State/Province:     Zip:
Country:    
Phone (include country code, if international):
Fax (optional):
 
4) Training Center Affiliation:    
5) Training season: Year-round  Seasonal
    If Seasonal, Start Month (ex. 05 for May):
    End Month (ex. 05 for May):
6) Qualifications of Applicant (Check all that apply):
MD/DO
PhD/EdD
NP/MA/MS/MEd
BA/BS/BSN
RN
PA
RT
LPN
AA/AS/AAS
NREMT-P/EMT-P
NREMT-B/EMT-B
CNA
Wilderness First Aid
Wilderness First Responder
State Certified Teacher
Wilderness Education Instructor
EMS Instructor
Firefighter
Fire Officer
Fire Service Instructor
Law Enforcement Officer
Law Enforcement Instructor
Lifeguard
Lifeguard Instructor
None of the above
Swim Instructor
7) Current Instructor Certifications (Check all that apply):
ARC Instructor or Instructor Trainer
        Babysitter’s Training
        HIV/AIDS
        Lay Responder First Aid and CPR/AED
        Lifeguard
NSC Instructor or Instructor Trainer
        Basic First Aid
        Bloodborne & Airborne Pathogens
        BLS Pro
        CPR/AED
        Pediatric First Aid, CPR & AED
        Standard First Aid, CPR & AED
AHA Instructor or Instructor Trainer
        BLS certified before June 2006
        BLS certified after June 2006
        Heartsaver
        ACLS
        PALS
AFO/CPO Instructor
StarGuard Instructor or Instructor Trainer
Ellis & Associates Lifeguard Instructor
YMCA Instructor or Instructor Trainer
State-certified EMS Instructor
Other
Swim Instructor
8) Have you ever been convicted of a felony?:
Yes  No
If Yes, please give detailed explanation:
9) Indicate the number of individuals you or your organization trained last year in the following topics through another nationally recognized organization. Enter 0 if none.
Lifeguards
Lifeguard Instructors
Swimming instructors
Swim lessons
CPR
Other
Organization:
Starfish Aquatics Institute
ARC
Ellis & Assoc.
YMCA
NASCO
Other
10) How did you hear about the HK Emergency Care and/or Aquatics Education Center?
Colleague/Friend
Internet Search
Tradeshow
ASHI Representative
HK Representative
Trade Journal/ Publication
Other
11) Professional References:
Contact Name: Phone:
                Email:
Contact Name: Phone:
                Email:
Contact Name: Phone:
                Email:
12) Who is your Intended Audience(s) for Emergency Care or Aquatics Programs? (Check all that apply):
Lifeguards working at/for the Training Center sites(s)
General Public
Day Care Providers
In-Hospital Health Care Professionals
Out-Of-Hospital EMS Professionals
Public Safety Professionals
Community and Workplace Lay Rescuers
Wilderness Trip Leaders and Guides
Military Personnel
Resort/Club Personnel
Foster Parents
Swim Coaches
Personal Trainers
Athletic Trainers
Aquatic Management Personnel
Other
13) Instructor Agreement:
Effective on the date of application, I understand and agree for myself; a) That approval and authorization as an HK or ASHI or Starfish Aquatics Institute Instructor is a privilege, not a right and may be revoked. b) To teach all programs and operate in accordance with the most recent and applicable version of the Instructor Guide and Training Center Administrative Manual .
If you agree with these statements, click here.

Please complete all questions before submitting your application, as you will be unable to return to the form later. We will contact you during the application review process if further information is needed.