Application to become a 

HeartMath® Certified Trainer to deliver Activating the Heart of Teams™

Welcome - Thank you for your interest in Activating the Heart of Teams™ Certification Program. Once we receive your application, a HeartMath representative will contact you to discuss program details and answer your questions.

Training Date

June 3, 10, 17, 24, Jul 1 / Teach Backs Jul 10, 11 / Wrap up Jul 12, 2024

Oct 1, 8, 15, 22, 29 / Teach Nov 6, 7 / Wrap up Nov 8, 2024

Reg close: 2 weeks prior to start date.

What type of training license are you applying for?

IndependentOrganizationalIndependent (Marketing your own services/Charging fees for service) or Organizatonal (Organization pays for training/Delivering within organization/No independent fees for service)

Name

First Name

M.I.

Last Name

Suffix

Please select... APRN AUD CAC CEO CFA CFP CHT CMT CNM CNO CPA CRNA DC DDS DMD DMin DNP DO DOM DPharm DPM DPT DVM EdD FNP JD LAc LCSW LMFT LMHC LMT LPC LPN MA MBA MD MDiv MEd MFT MPH MS MSN MSW ND NMD NP OD OMD OT PA-C PE PharmD PhD PsyD PT RD RDH RN RN, BSN RPh RPsych RT RYT SLP SLPD

Company Info

Company

Organization

Title

Department

Address & Contact Information

Address

City

State

Please select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NT NS ON PE QC SK YT

Zip

Country

Please select... United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe

Email Address

Daytime Phone

Mobile Phone

Page 2

What is your primary market?

What type of teams will you be working with? (Education, First Responders, Corporate, Health Care, Sports, etc.)

How many teams do you plan to facilitate in using the Activating the Heart of Teams™ (AHT) program within the next 12 months?

How comfortable are you in public speaking and using PowerPoint slides?:

Beginner (no experience)Intermediate (moderate)Advanced (expert)

Briefly describe your presenting, coaching, mentoring or facilitation skills (1,000 character limit).

What level of experience do you have with facilitating team conflict?:

Beginner (no experience)Intermediate (moderate)Advanced (expert)

Explain the reasons you want to become certified in Activating the Heart of Teams™ (750 character limit)

If you are already a HeartMath client/customer, who is your primary contact?

Please select... N/A Brian Kabaker Carol Thompson Christiana Bishop Claudia Davenport Dan Bishop Deborah Rozman Howard Martin Jeff Goelitz John White Katherine Floriano Paula Elliott Robert Browning Robert Massy Rollin McCraty Sarah Moor Sibyl Cryer Stephanie Herzog Tom Beckman Toni Roberts

Which of the following HeartMath®-based certifications have you completed?

Coherence Advantage™ - A HeartMath® Certified Trainer ProgramResilience Advantage™ - A HeartMath® Certified Trainer ProgramBuilding Personal Resilience™ - a HeartMath® Mentoring CertificationHeartMath® InterventionsHeartMath® Clinical Certification for Stress, Anxiety and Self-Regulation
The Resilient Heart™ - Trauma-Sensitive HeartMath® Course and CertificationNone

Page 3

If applying for an organizational license: Who in your organization supports your HeartMath training objectives? What is that person's title and role in the organization?

Upon completion of the certification training, please indicate how you would prefer your name to appear on your certificate.

Agreement

Independent Trainer License Agreement

Agreement

Organization Trainer License Agreement

I have read and agree to the terms and conditions in the HeartMath Trainer  License Agreement.

Yes

I give my permission to have recordings of the training days with my voice and picture to be distributed to staff and training attendees for future training purposes. I agree not to download or share these recordings with others.

YesNo

I give my permission to share my contact information with certification class attendees solely for training communication purposes. I agree to not distribute the shared participant contact information with others.

YesNo

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