CHT ORDER FORM V3
  • cPAD Order Form

    cPAD Order Form

    Hello, and thank you for choosing to work with The Community Heartbeat Trust, the UK’s leading community defibrillator charity. Please complete this form as fully as possible and once submitted we will get straight to work processing your request!
  • Equipment Selection

    Equipment Selection

    Please click/tap on the button below to select your equipment.

  • DEFIBRILLATOR

  • Lifeline View (Defibtech)
  • AED 3 Semi-Automatic (Zoll)
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  • Vivest X1
  • Vivest X3

  • CABINET

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  • AWARENESS SESSION

  • For a breakdown of what is included please visit Awareness Session. Zoom training for up to 100 participants is also available as an option.

  • Additional Services

    Additional Services

    Annual support, installation and other services to make the most out of your project. If you are unsure of V.E.T.S or 999 Phones you can contact us about these later.

  • For a reminder of costs please visit Annual Support.

  • VOLUNTEER EMERGENCY TELEPHONE SYSTEM (V.E.T.S)

  • V.E.T.S Funding is available for up to £400 per community in Suffolk. this funding is limited so if it is of interest please select that which applies...

  • For further information on the types of system and what this is please visit V.E.T.S volunteer Emergency Telephone System. 

  • EMERGENCY PHONE

  • GSM PHONE
  • Landline Phone
  • Scheme Co-ordinator Contact Details

    Scheme Co-ordinator Contact Details

    This person will be the central point of contact for the purposes of implementing and discussing your defibrillator project.

  • This address will be used for the purposes of posting information, paperwork and any other associated articles that relate to your defibrillator project.

  • Invoice Contact Details

    Invoice Contact Details

    The person or body responsible for payments and who the invoice for the project will be addressed to.
  • Delivery Contact Details

    Delivery Contact Details

    This person will be the main contact and recipient for the delivery of the defibrillator equipment.
  • Defibrillator Location

    Defibrillator Location

    Please confirm the type of location where you are going to place your defibrillator so we can ensure accurate information is provided onto the governance system.

  • Battenburg signage for 3 sides of your KX100 telephone box is also available, if of interest you can see a preview here. You can add these to your order in addition to the included signage for £65.00

  • Telephone Box Paint Application 

    Please let us know if you would like us to apply to BCF for free red and gold paint on your behalf to renovate your telephone box. If you select yes once you have submitted there will be a link on the thank you page to submit details of whom will be the main point and recipient of details regarding this application.

  • Defibrillator Reporters (WebNos)

    Defibrillator Reporters (WebNos)

    Please confirm whom will be responsible for reporting on your defibrillator. The people listed below will be sent a log on link and instructions on how to report.

  • REPORTING CONTACT

  • Installation Address

    Installation Address

    If you are ordering a defib that will be mobile please enter the keepers address below of where the defib will be kept overnight
  • Hosting Agreement

    Hosting Agreement

    This section is only to be completed if the premises to which your cabinet is attached does not belong to or is not rented directly by your club.  If the building is part of a multi-sports ground or community organisation of which your club is a part and/or you pay rent to that entity, then this section must be completed by an authorised person from that organisation.

  • This hosting agreement is made between:

  • and The Community Heartbeat Trust Charity. (The cPAD Scheme) The Community Heartbeat Trust, working with:

  • has established a defibrillator available for public use at the location:

  • This location is managed by the host who has given unrestricted permissions for the establishment of the cPAD device for an unlimited period, or until such time as external factors will require a change in the hosting site.

    Responsibilities of the Host:

     

    • The Host will provide a rent free location for the cPAD box and contents for as long as this agreement is in place.
    • The Host will not take any action to prevent unlimited public access to the cPAD equipment
    • The Host will provide an unmetered electricity supply to the cPAD equipment via a Residual Current device (RCD) or similar fused source (e.g plug).
    • The Host will not restrict the electricity supply in any way but shall not be responsible for any interruptions in service caused by events outside its reasonable control.
    • The Host will provide access to the emergency services and their representatives to the cPAD device on request, and will not restrict or encumber access to the public.
    • The Host has the right to view evidence of any theft, damage and public liability insurances by the cPAD scheme.
    • Host will assist with weekly checks on the equipment.

    Responsibilities of the cPAD scheme:

    • The cPAD scheme will pay the Host a reasonable sum to cover the costs of any electricity used, estimated to be between £3 and £30 per annum, the actual value to be agreed with the Host. The Host may choose to waive any charges.
    • The cPAD scheme will be responsible for the maintenance of the cPAD site and the cPAD itself such that it shall be in proper working order, and rescue ready, at all reasonable times.
    • The cPAD scheme shall be responsible for any damages caused by this device to the location, and will reasonably compensate the Host in the event of damage being caused in the locating or use of the cPAD.
    • The cPAD scheme is responsible for arranging any insurance on the cPAD equipment, to include theft, damage and public liability. CHT has PLI to the level of £5 million.
    • The cPAD scheme will agree to support the cPAD site through either annual support agreements or providing ongoing costs to cover electrodes, batteries, rescue kits, where possible and also arrange initial training and awareness programmes locally.
    • The cPAD scheme will put in place a full Governance system to include record keeping, regular service checks, notification of in/out of service requirements, training records, policies and procedures, regular reporting to all stakeholders (including but not exclusively the local ambulance service) and make sure the equipment is serviced and stored in line with the manufacturers recommendations.
    • The cPAD site absolves the Host from any liabilities save those that are as a result of the Host’s own doing.
  • Clear

  • Terms & Conditions

    Please Read/scroll to the bottom of the terms outlined below and click agree otherwise you will not be able to submit.
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