Instructor Application Form
For Health & Safety Instructor
(please
type or print)
1. Personal
Information
I am applying to teach:
Name of Course
Last Name: First
Name:
Home Address:
Home Phone Number: Cell Number (optional):
Email Address: Date of Birth:
Employer:
Employer’s Address:
Employer’s Phone Number:
2. Education
High
School City State Dates Diploma/Degree
College City State Dates Diploma/Degree
Other City State Dates Diploma/Degree
Continuing education obtained within the past two years that pertains to the course you wish to teach:
3a. Experience
Have you had teaching experience? Yes No
If yes, please complete the following:
Name of Organization:
Address:
Nature and date of teaching
experience:
3b. Experience
Have you had related work experience? Yes No
If yes, please complete the following:
Name of Organization:
Address:
Nature and date of teaching experience:
4. License, Certification
Do you have a professional License, eg, RN, MD? Yes No
If yes, give the license number and
state(s) in which you are licensed:
5. Goals and Plans
My goals for taking this Introduction to Health Services Education and subsequent instructor specialty courses are:
I plan to teach the following groups:
6. Candidate’s Agreement
In return for the instructor training I receive, I agree to work with the Red Cross chapter or station in planning, teaching, and providing records and reports for the course in which I receive my training.
Signature
of Candidate Date
Endorsement of
Candidate:
The Island County Chapter of the American Red Cross recommends as a candidate for instruction.
Signature of chapter
representative Title Date