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Work at Gold Cross
Pay My Bill
Contact Us
Donate
About Us
Mission, Vision, Values, Scope
Expertise
History
Our Services
Regional Approach to Care
Hospital Resources
Employee Log In
Our Team
Meet Our Leadership
Our Medical Team
Healthcare Partners
Give a Thumbs Up!
Why Work for Gold Cross
Community
Committed to Our Community
PR/Community Outreach
HeartStart Foundation
PulsePoint
Register an AED/Find an AED
Stop the Bleed
Crisis Support for Professionals
Scholarship Fund
Community Fund
Give
Training Classes
Overview
CPR/AED Training
First Aid & Bloodborne Pathogens
Oxygen Administration
Training Consultation
BLS for Healthcare Providers
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Class Registration
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AED Program Matching Grant
Automated External Defibrillator (AED) Program Matching Grant
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
No
If so, how many and what type of AED(s)?
*
Is this application for a replacement AED?
*
Yes
No
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
*
If you are human, leave this field blank.
Submit
Dispatch
(920) 727-3034
Billing
(920) 727-3020
Fax Number
(920) 727-3033
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