AED Form | Chase McEachern AED

Defibrillator Request

Organization Details:

Primary Business Activity:

Organization Name:

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Website (if you have one)

Contact Details:

Name

Phone

Application Questions:

1. Is Your Organization, Facility Or Group Applying For The AED Donation Charitable Or Not For Profit? If Charitable, Please Provide Approved Charitable Number, If Not For Profit, Explain The Nature Of Your Business

2. How Did You Hear Of The CMMF?

3. Please Explain How The Donated AED Package Will Be Beneficial To Your Organization And Its Needs. Be As Specific As Possible

4.Has Your Organization Commenced Any Fundraising Activities To Date And If So, How Much Has Been Raised?

5. What Is The Approximate Number Of People That Utilize Your Location/Facility On A Daily Basis?

6. Approximately What Percentage Of Daily Facility Users Are Over The Age Of 35 Years Old?

7. Does Your Facility Currently Have An AED On-Site?

8. Who Will Provide Maintenance And/Or Servicing If You Are Selected?

9. Has Relevant Staff Been Trained On The Usage Of An AED?

10. If You Have Not Received Training On AEDs, Will You Proceed To Do So?

11. Where Do You Plan To Deploy Your AED Within Your Location/Facility And Will It Be Accessible To All That Use Your Facility?

12. Please Provide Any Other Information You Deem Important.

Signature

Your Signature

Position

MOU

If you or your Not For Profit group is chosen to receive a defibrillator.

Must agree to the following

1. Registration of defibrillator and location with your Local EMS or PAD program

2. Maintain the defibrillator in good faith by

a. Monthly check to see if defibrillator is working then record date on a log sheet

b. Replace pads when expired at your expense

c. Replace battery when expired at your expense

d. If defibrillator is used all pads and batteries have to be replaced

e. Approximate after eight years unit has to be replaced with a new one. At your expense.

As long as the defibrillator is maintained you cannot be sued Under the Chase McEachern Act.

I have read the MOU and understand and agree to the terms.

Your Signature