SuperHeart Program Enrollment Form
Please complete all questions below to be considered for the SuperHeart Program.
Eligibility
Does your organization serve youth between the ages of 12-22?
*
Yes
No
Has your organization been part of the SuperHeart Program previously?
*
Yes
No
Is your organization a sports team?
*
Yes
No
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Next
At this time, you are not eligible for the SuperHeart Program.
Should you have questions about eligibility, please contact Contact@livingforzachary.org.
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Finish
Enrollment Questions
School/Organization Name
*
School District (optional)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Website
Type
*
Please Select
Public School
Private School
Charter School
Organization
Setting
*
Please Select
Rural
Urban
Suburban
Grades Served (Select all that apply.)
*
6th
7th
8th
9th
10th
11th
12th
Total Enrollment Number
*
Race/Ethnicity (The total number from each category should equal the number of enrolled students provided above)
*
Percentage of students on free lunch (optional)
Percentage of students on reduced lunch (optional)
If a school, are you a Title I school? (optional)
Yes
No
N/A
Primary Contact's Name
*
First Name
Last Name
Primary Contact's Title
*
Primary Contact's Email
*
example@example.com
Primary Contact's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Administrator Name
*
First Name
Last Name
Administrator Email
*
example@example.com
Administrator Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about the SuperHeart Program?
*
Please Select
Social Media
Living for Zachary Website
Living for Zachary Staff
Google/Search Engine
Family/Friend
School/District
Work/Employer
Service Organization
Faith-based Organization
How many indoor AEDs does your campus currently have?
*
How many outdoor/portable AEDs does your campus currently have?
*
How many total AEDs does your campus currently have?
*
Has your organization received an AED from Living for Zachary in the past?
*
Yes
No
Has your organization offered youth heart screenings in the past?
*
Yes
No
When did the most recent heart screening event take place?
*
-
Month
-
Day
Year
Date
What organization provided your heart screenings?
*
Submit
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