Training Site Alignment & Candidate Application Packet

Complete the fields below once and sign a single time. You'll preview the finished packet before anything is submitted.

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Full Name *

Email Address *

Phone Number *

Mailing Address *

City *

State *

Zip Code *

Role / Title *

Renewal date of provider card *

Date *

Enter your original alignment date here

I acknowledge that I have read, understood, and agree to all terms in the Dispute Resolution Policy, Instructor Compliance Agreement, Quality Assurance Plan, Instructor Alignment Agreement, and AHA Instructor Candidate Application. *

Digital signature *

Sign above using your finger, stylus or mouse.

Electronic signature consent. By drawing or typing your name above and submitting this packet, you agree that your electronic signature is the legal equivalent of your handwritten signature and that it may be used to sign, execute and authenticate this document. You consent to conduct this transaction electronically under the U.S. E-SIGN Act and the Uniform Electronic Transactions Act (UETA), and you certify that all information provided is true, accurate and your own. You may request a paper copy of the signed packet at any time by contacting In RaMiyah's Hands.

Your signature is applied only to this packet. We do not store your application details in a database.