Organizations Legal Name registered with Secretary of State (SOS) *

Business & Owner Legal Name registered with Secretary of State (SOS) *

Official Business Address as Registered with Secretary of State *

Business Phone Number *

Business Email *

Describe type of Business *

Please check all the disciplines you will be instructing.

BLS Instructor

BLS Provider

BLS Renewal

HeartCode BLS

Heartsaver Instructor

Heartsaver CPRAED First Aid

Heartsaver CPR

Heartsaver First Aid

Heartsaver Pediatric

Heartsaver Blended Learning Courses

HandsOnly CPR

ACLS Provider(Initial/Blended Learning)

ACLS Renewal

PALS Provider(Initial/Blended Learning)

PALS Renewal

Are you currently a Training Site at another Training Center? *

YES

Current Training Center Name/Contact Information

Are you currently a BLS Instructor? *

YES

Are you a current TCF? *

YES

How many participants did you instruct per year (BLS & Heartsaver)? *

2023 TOTAL:
2024 TOTAL:

Do you currently issue eCards? *

YES

Do you currently use Enrollware for course records management? *

YES

Do you currently use Directive Feedback Manikins? *

YES

Do you currently have a website? *

YES

Are you familiar with AHA ATLAS? *

YES

How far in advance do you post your courses for participants to register for? *

Days in Advance

Weeks in Advance

1-3 Months in Advance

3-6 Months in Advance

6-12 Months in Advance

Do you host on-site courses at businesses? *

YES

Do you host community courses? *

YES

How often do you instruct courses? *

Daily

Weekly

Monthly

Every other month

Several times a year

Please explain current refund policy for a course? *

Please explain current no-show policy for a course? *

Please explain current cancellation policy for a course? *

Do you currently accept Visa, Mastercard, American Express, Discover? *

YES

Please locate, then copy & paste below the American Heart Association payment disclaimer below *

Do you currently use the American Heart Association Training Site Logo? *

YES

Do you currently carry liability insurance? *

YES

REQUIREMENT: Training Sites are required to maintain Commercial Liability insurance with a limit equal to or greater than $1,000,000 and a deductible no greater than $1,000, regardless of disciplines applied, from a carrier rated A, VII, or better.

Check one please *

I was the Training Site Coordinator who completed this application

I was NOT the Training Site Coordinator who completed this application

Sign Below: *

Clear

Legal Signature

Date *

Phone number *

E-mail *

By e-signing this application above I have provided Bayside CPR & Training Center, LLC with truthful and accurate information to be considered as an authorized American Heart Association Training Site under the direction of Bayside CPR & AED Training Center. In the event any information is falsified, this application and/or Training Site agreement will be terminated immediately.