American Sport Education Program
Instructor Application (Fields marked with * are required)

Please be sure you are affiliated with a training center prior to submitting this application.
1) Application for *: New Instructor Certification Renewal
 
2) Instructor Candidate Information *:
First Name:   Last Name:
         Email:
Address1:
Address2:
City:                State/Province:     Zip:
Country:    
Phone (include country code, if international):
Fax (optional):
 
3) Have you ever had a license or certification suspended, revoked, or denied, including certification by any of the organizations listed below, or been convicted of a felony in any state? *:
Yes  No
If Yes, you may still be eligible for Instructor authorization, but you must provide a detailed explanation:
 
4) Who is your Intended Audience(s) for CPR/AED for Coaches course? (Check all that apply) *:
Scholastic Coaches (Grades 5-12)
Youth Sport Coaches (Up to Age 14)
Competitive Club Sport Coaches
College/University Sport Coaches
General Public
Other
5) Training Center Affiliation *:
 
6) Reciprocity: If you are currently a certified instructor for any of the following organizations, you may be exempt from completing Part B of the instructor training process. Please check all that apply.
Media First Aid Instructor
        Advanced First Aid & CPR/AED
        CPR/AED & First Aid
        Adult-only CPR/AED & First Aid
        CPR/AED
        First Aid
        Bloodborne Pathogens
ARC Instructor or Instructor Trainer
        Babysitter’s Training
        HIV/AIDS
        Lay Responder First Aid and 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
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
AFO Instructor
Starguard Instructor or Instructor Trainer
State Certified EMS Instructor
Other
7) Instructor Agreement *:
Effective on the date of application, I understand and agree for myself; a) That approval and authorization as an ASEP CPR/AED for Coaches 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.