SuperHeart Program Enrollment Form

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?
Has your organization been part of the SuperHeart Program previously?
Is your organization a sports team?

At this time, you are not eligible for the SuperHeart Program.

Should you have questions about eligibility, please contact Contact@livingforzachary.org.

Enrollment Questions
School/Organization Name
School District (optional)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization Website
Type
Setting
Grades Served (Select all that apply.)
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)
Primary Contact's Name

First NameLast 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 NameLast 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?
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?
Has your organization offered youth heart screenings in the past?
When did the most recent heart screening event take place?

MonthDayYear
Date
What organization provided your heart screenings?
Should be Empty:

Eligibility