Defibrillators Application Form

Organization Details


PLEASE COMPLETE THE FOLLOWING 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?

Less than 100100 to 500500 to 1000Over 1000


6. Approximately what percentage of daily facility users are over the age of 35 years old?

0% to 25%25% to 50%50% to 75%75% to 100%


7. Does your facility currently have an AED on-site?

Yes, AED on-siteNo, no AED on-site


8. Who will provide maintenance and/or servicing if you are selected?

Your local EMS serviceAED manufacturerNobodyOther


9. Has relevant staff been trained on the usage of an AED?

Most relevant staffSome relevant staffMinimal relevant staffNo Staff


10. If you have not received training on AEDs, will you proceed to do so?

YesNo


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.

I have filled out this form to the best of my knowledge & have signed it via electronic signature

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Donation Total: $10.00