Application for AED Donation Program

Please complete this form to apply for a donated Automated External Defibrillator (AED) for your facility or organization.

Facility/Organization Name *

Contact Person Name *

Full Name

Email *

Phone *

Street Address

Country

State

City

Postal Code

Type of Facility/Organization *

common.other_option

Number of people served daily (average) *

Is this a non-profit organization? *

Yes

No

Do you currently have an AED onsite? *

Yes

No

If you currently have an AED, please specify its approximate age (in years) and its functional status. *

Why is your facility in need of an AED donation? (Please explain the primary risk factors or reasons for need.) *

Who would the donated AED primarily serve? (Select all that apply) *

Have staff members or volunteers received formal CPR/AED training in the last two years? *

Yes, a significant number of staff are trained.

Yes, but only a few key personnel are trained.

No, staff currently lack formal training.

Training is scheduled to occur soon.

Rate the severity of any medical emergencies or incidents (e.g., cardiac events, severe injuries) that have occurred onsite previously. *

None/Very LowFrequent/Serious

How would receiving an AED impact your community? (Describe the potential benefit and preparedness improvement.) *

Would you be willing to participate in social media/news coverage regarding the donation if selected? *

Yes, we would be happy to participate.

No, we prefer to keep the donation private.

Upload area for photos of the facility (Optional: Exterior and interior views where the AED might be placed.)

Click to upload

Any additional information you would like us to know regarding your application.