AED - Formstack

AED Donation Program Application
Eligibility Requirements:

-Work directly with ages 12-22 years old
-Demonstrate a financial need for an AED
-Exhibit a lack of AED coverage for the proposed facility
-Located in Texas

If you are affiliated with a school district, the AED donation is awarded at the school-level and an application needs to be submitted for each eligible campus.
Indoor AED donations include a wall mount cabinet and outdoor AED donations come with a yellow waterproof case. If the AED will be taken regularly to a site that does not have an AED and needs protection from the elements, then an outdoor AED is recommended. The AED device is the same for indoor or outdoor use. Please refer to this image to help select the type of AED your organization needs.
Is your organization located in Texas?*

YesNo
Does your organization serve between the ages of 12-22?*

YesNo
Is your organization a for-profit medical facility?*

YesNo

At this time, your organization is not eligible for the Living for Zachary AED Donation Program.

The program serves ages 12-22 within the state of Texas.

Organization Name*
Primary Contact's Name*
First and Last Name
Primary Contact's Title*
Address (facility where the AED will be placed)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Organization Website*
Select the type of organization that most closely fits your company.*

ChurchCommunity CenterSports TeamScoutsSchoolGymMedical FacilityOther
What is the primary youth function / purpose of your organization?*
How is your organization funded?*

Non-profitFor-profitOther
Does your organization serve youth 12-22 years old?*

YesNo
Provide an estimated number of youth in each age group that your organization serves.*
How many total youth are served by your organization?*
How many youth does your organization serve? The combined total should equal the number of youth served.*
How many youth in each ethnic background does your organization serve? The combined total number should equal the number of youth served. *
What are your hours of operation?*
How many days per week is your facility used?*
What is the total number of hours per week that youth spend at your facility or participate in your organization's activities?*
What year was your organization established? *
Numbers only
How many individuals does your organization employ? *
How many of your employees are CPR trained?*
Estimated number of staff, board members, long-standing volunteers, etc. that need to be CPR/AED certified within your organization.*
How many volunteers does your organization have? *
What is the size of your facility in square feet?*
What is the size of your property in acreage?*
How many buildings does your facility have?*
Does your organization currently have any AEDs onsite?*

YesNo
Has your organization received an AED in the past from Living for Zachary?*

YesNo
How many AEDs do you currently have onsite?*
Where are your AEDs currently located?*
How many total AEDs is your organization requesting? This must equal the total number of indoor and outdoor AEDs you are requesting.*
When calculating the number of AEDs needed consider the following: 3-minute response time which means an AED can be reached from anywhere in the building and brought back to a victim within 3 minutes of collapse.
Are you looking to replace an AED?*

YesNo
Has the AED failed its self-test which means it is beeping/chirping?*

YesNo
How many AEDs are you looking to replace?*
Explain why you are looking to replace the AEDs, make and model, and any issues you are having with the current AED devices.*
How many indoor AEDs is your organization requesting? *
Enter 0 if you do not need any indoor AEDs.
If your organization is awarded indoor AED(s), where exactly will each be located in your building?*
How many outdoor AEDs is your organization requesting? *
Enter 0 if you do not need any outdoor AEDs.
If your organization is awarded outdoor AED(s), where will the device(s) be kept year-round? When not in use, it is recommended to be stored in a climatized area that is not locked.*
If you are awarded an outdoor AED, what off site activities will the AED be taken to (community events, physical activities, etc.)?*
If an outdoor AED is awarded, would someone within your organization be able to coordinate the transportation of the AED to on-and-off- site activities year-round?*

YesNo
Describe the financial constraints that prohibit your organization from purchasing an AED.*
Do you have a physician who is willing to oversee your AED Program?*

YesNo
Physician overseeing your AED Program*
AED Coordinator's contact information: The staff member will perform the monthly AED service check on batteries and pads.*
CPR Contact*
Upload a floor plan or Google Map of your entire facility showing the current location of AEDs and location of requested AEDs. Label them AED requested and AED current. For outdoor AEDs, screenshot the field/green space using Google maps. Include a scale on the map (e.g. 1 inch = 200 yards)*

Cancelof
Add additional details that you think would be helpful regarding your organizations AED application (optional).
How did your organization learn about the Living for Zachary AED Donation Program?*

Social MediaLiving for Zachary WebsiteGoogle/Search EngineEmailSchool/districtLiving for Zachary StaffAmerican Heart AssociationCommunity or Faith-based OrganizationOther
With my signature, I attest that the information is true and accurate.*
Should be Empty:

AED Donation Program Application

At this time, your organization is not eligible for the Living for Zachary AED Donation Program.