Training Site Application Training Site Application Step 1 of 4 25% Training Site Contact InformationTraining Site Business Name: Legal Structure*sole proprietorshipgeneral partnershiplimited partnershiplimited liability partnershipcorporation (including S corporations)professional associationslimited liability companiesbusiness trustsgovernment entityTraining Site Coordinator* First Last AHA Instructor Status:*Current AHA InstructorApplying for AHA Instructor TrainingTraining Site Coordinator Instructor ID Number:*Go to http://ahainstructornetwork.americanheart.org – login using your username and password. Your Instructor ID number will appear on left side of page. If you do not have a login, please create one. Email* Enter Email Confirm Email Work Phone*Mobile Phone*Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address Billing Address Different from Physical Address Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Sales Tax Training site is exempt from sales tax. Upload Sales Tax CertificateMax. file size: 256 MB.Certificate of General Liability Insurance:*Max. file size: 256 MB. Courses and EquipmentRequested Disciplines:* Heartsaver Basic Life Support Advanced Cardiac Life Support Pediatric Advanced Life Support CPR AED EquipmentIndicate Quantity of Equipment Training Site Currently Possesses:Adult CPR ManikinsChild CPR ManikinsInfant CPR ManikinsAED TrainersPocket Masks / ValvesAdult manikins provide audio and visual feedback of compression rate and depth as required by AHA:*YesNoHeartsaver EquipmentIndicate Quantity of Equipment Training Site Currently Possesses:Heartsaver First Aid CPR AED DVD (2020 Edition)Heartsaver Instructor Manual (2020 Edition)Epinephrine Pen TrainersHeartsaver Student Manuals (2020 Edition)BLS EquipmentIndicate Quantity of Equipment Training Site Currently Possesses:BLS Provider DVD (2020 Edition)BLS Instructor Manual (2020 Edition)Adult BVMsChild BVMsInfant BVMsBLS Provider Student Manuals (2020 Edition)ACLS EquipmentIndicate Quantity of Equipment Training Site Currently Possesses:ACLS Provider DVD (2020 Edition)ACLS Instructor Manual (2020 Edition)Adult Airway Manikin (intubation)Intubation KitALS Monitor / SimulatorACLS Provider Student Manuals (2020 Edition)PALS EquipmentIndicate Quantity of Equipment Training Site Currently Possesses:PALS Provider DVD (2020 Edition)PALS Instructor Manual (2020 Edition)Pediatric Airway Manikin (intubation)Pediatric Intubation KitALS Monitor / SimulatorIO Needle / Drill SetsPALS Provider Student Manuals (2020 Edition)Will the Training Site distribute AHA student workbooks to each student?*YesNo Affiliated InstructorsList All Instructors (exclude Training Site Coordinator)First NameLast NameInstructor IDHS / BLS / ACLS / PALS Forecast, Values, Growth PlanCode One only aligns with Training Sites that share the same values for quality programming and superior customer service. We seek Training Sites that can demonstrate these values through established business plans, policies, procedures, and favorable growth forecasts. Code One wants to help its Training Sites grow, meet customer needs, and exceed their expectations.Forecast*If your Training Site is already operating, how many participants have you trained each quarter for the past year? If your Training Site is new, how many participants do you expect to train in the next year? What assumptions have you made to determine this number?Market*What is your target market? Who are your primary and secondary customers? What geographical area will you cover?Quality*What policies and procedures do you have in place to assure quality of program delivery and to ensure a positive customer experience? Growth Plan*Briefly describe your plans to grow your Training Site. How will you accomplish these plans? Include any measurable goals your Training Site has established.NameThis field is for validation purposes and should be left unchanged.