Tidewater Center for Life Support Training
Training Center Faculty
Application Form
The Training Site Coordinator identifies potential Training Center Faculty. The Training
Center Faculty candidate should complete this application form and the Training Site
Coordinator should present this form during a regular meeting of the TCLS Community
Training Site Committee. The Training Site Committee will discuss the candidate and
provide a recommendation for approval/denial to the CTC Coordinator. Note: Candidates
at the BLS level must be an Instructor Trainer, or must complete an Instructor Trainer
course prior to full recognition as a Training Center Faculty.
Candidate's Full Name: __________________________________________________
Candidate's Address: Street/PO ____________________________________________
City________________________________ State ___________ Zip ______________
AHA Discipline and level (circle):
ACLS Instructor
PALS Instructor
BLS IT
ACLS CD
PALS CD
BLS RF
ACLS RF
PALS RF
Training Site: ___________________________
This candidate is a(n): RN MD EMS Provider FF Other _____________________
The candidate teaches an average of _____ BLS/ACLS/PALS classes per year.
The candidate has been an instructor, IT, CD or RF for _______________ years.
The candidate is an active participant in their training site. Y N
The candidate expresses a willingness to fulfill the responsibilities of a TC Faculty. Y N
This candidate is recommended by ___________________________________.
TS Coordinator
Candidate Signature: ______________________________ Date:__________________
TS Coordinator Signature :__________________________ Date:__________________
CTS Committee action: Approved for term of one year _____
Not Approved _____
Approved for discipline(s): BLS ACLS PALS
CTS Chairperson signature: _________________________ Date: __________________
CTC Coordinator action: Approved for term of one year _____
Not Approved _____
Approved for discipline(s): BLS ACLS PALS
CTC Coordinator signature: _________________________ Date: __________________
Term: __________________ to _____________________
Rev. 7/02