AED Program Matching Grant

Automated External Defibrillator (AED) Program Matching Grant

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Organization and Contact Information

Organization Name *

Organization Address *

County in which organization is located *

Supervising Official *

Contact Person *

Contact Person Email *

Contact Person Phone *

Fax Number

Organization's Corporate & Tax Status *

Organization Staffing *

Approximate Number of Personnel *

Annual Equipment Budget *

Total Annual Budget *

Organization's Geographic Service Area *

Service Area Square Miles *

Nearest Large or Medium Sized City *

Other Funding Sources for this AED Fund Request

How Your Organization Will Use the AED

Does your Organization currently own or have access to an AED? *

Yes

If so, how many and what type of AED(s)? *

Is this application for a replacement AED? *

Yes

If your organization is awarded a matching grant for an AED, for what major purpose(s) will it be used? *

If your organization is awarded a matching grant for an AED, where will it be placed and primarily used? *

Knowing that other organizations will be competing for a limited number of AED matching grants to be awarded by the Gold Cross HeartStart Fund, please describe how your organization intends to use the AED and/or how it will improve your emergency response or other capabilities? *

Please site specific examples within the last three years where an AED would have enhanced your organization’s response. *

Is there any other information that your organization would like the selection committee to consider? *

How did you learn about this AED matching grant program? *

Online Signature *

Dispatch

(920) 727-3034

Billing

(920) 727-3020

Fax Number

(920) 727-3033

AED Program Matching Grant

Organization and Contact Information

How Your Organization Will Use the AED

Dispatch

Billing

Fax Number

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