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Please tell us your first and last name.

First Name

Last Name

What is your full mailing address?

Street Address 1

Street Address 2

City

State

Zip Code

What is your email address?

Email Address

What is the best daytime telephone number to reach you at?

Daytime Telephone

What is the best evening telephone number to reach you at?

Evening Telephone

Are you affiliated with an organization that would be interested in using this program as an outreach / public education program? If so, identify the organization and provide contact information for the appropriate person (if not you).

Please explain why you want to be a part of this program? How might you contribute to the overall goal of reducing injuries, illnesses, and fatalities in farming and agriculture in your community?

In order to be considered as an instructor for this program, you are required to have prior experience as an instructor in a relevant field. Certifications/experience that qualifies you include (but are not limited to):

Public safety instructor certification, including EMS / Fire / Law Enforcement;
OSHA Outreach Training Program Instructor (Completion of OSHA 500/501);
VT-recognized Trainer for Hazardous Chemicals in General Industry or Fall Protection in General Industry;
BCSP-recognized Certified Instructional Trainer;
American Heart Association, American Red Cross, or National Safety Council CPR/First Aid instructor; or
Instructor/faculty at an accredited college or university;

Please upload a copy of documents that support your request to be an instructor in this program.

Orientation will consist of a Zoom session in late March / early April. Please outline what days/times generally work best for you to be able to attend an orientation program.

Virginia Tech asks that each instructor perform a minimum of 10 contact hours of instruction / train a minimum of five persons for 1-2 hours over the next six months. Are you willing to commit to that goal?

Yes
No