Wayne HealthCare Foundation AED Application

Wayne HealthCare Foundation AED Application

Wayne HealthCare Foundation, in partnership with Midmark Corporation and Spirit Emergency Medical Services, provides AEDs and training to non-profits. Eligibility: Organization must be located in Darke County or the surrounding area of Ohio/Indiana
Date*

MonthDayYear
Date
Organization Legal Name*
Tax Exempt Status*

501(c)(3)Other
Tax ID Number*
Please provide a copy of your IRS determination letter*

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Name of Executive Director*

First NameLast Name
Organization address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Requestor*

First NameLast Name
Requestor Phone Number*
Please enter a valid phone number.
Requestor Email*
example@example.com
Type of Request*
New Request – AED Unit: HeartSine 350P Or Philips HeartStart
Retail Price: $1,590
Grant Coverage: $1,060
Your Organization’s Cost (if approved): $530 per unit

Each AED package includes:
- HeartSine 350P or Philips HeartStart AED
- Adult Pad/Battery Pack
- Pediatric Pad/Battery Pack
- Rapid Response Kit
- Carrying Case
- Alarmed Storage Cabinet
- AED Signage
Number of AED Units Requesting
List the Location(s) where the AED(s) will be placed.
Maintenance Supplies
prevnext( X )
HeartSine 350p Adult Pad/Battery Pack HeartSine 350p Adult Pad/Battery Pack
$78.67 Quantity



HeartSine 350p Pediatric Pad/Battery Pack HeartSine 350p Pediatric Pad/Battery Pack
$93.00 Quantity



Philips HeartStart Battery Philips HeartStart Battery
$53.55 Quantity



Philips HeartStart Adult PadsPhilips HeartStart Adult Pads
$22.38 Quantity



Philips HeartStart Pediatric Pads Philips HeartStart Pediatric Pads
$32.58 Quantity



Total

$0.00
Payment Acknowledgment

Check- Make checks payable to Wayne HealthCare Foundation, memo AED Program. Checks may be dropped off or mailed to 835 Sweitzer St. Greenville, OH 45331Credit Card- After form submission, you will be redirected to complete your order via credit card on the Wayne HealthCare Foundation webpage. By clicking this box, I confirm I have read the above form and will complete my order on the next page. Incomplete payments may delay the process of your application.
Reason for Request*
Organization's Mission Statement*
Does the organization have an identified medical professional (i.e, nurse, provider, EMT) volunteering/working at your organization to oversee the AED unit and maintenance?*

YesNo
Name of medical professional*

First NameLast Name
To have an AED on site, you are required to have staff or volunteers trained in CPR and how to properly maintain the AED unit. List the names and dates of CPR/AED training for your personnel. *
Important Information
- Call Wayne HealthCare Foundation at 937-569-6408 with any questions.
- Spirit Medical has offered to provide this training to your organization through a voucher program for up to ten participants. Contact Brian Hathaway or Carie Pope at 937-548-2800.
- To have an AED on site, your organization is required to notify in writing the rescue squad that covers your area of the existence of an AED. Please attach a copy of the letter you intend to send to the appropriate rescue squad with this application.
- Your organization, Wayne HealthCare Foundation & Midmark Corporation will share the cost, 1/3 each of the AED.
- By submitting this form you acknowledge the above information is true and we hold harmless Wayne HealthCare Foundation, Midmark Corporation, and Spirit Medical Services in any activity associated with this AED program. This AED is now property of the applying organization and will be maintained by the applying organization.
Copy of letter submitted to rescue squad*

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Additional Maintenance Information

AED manufacturer warranties typically are 8 years for the unit, 4 years for the battery, and 2 years for pads. You can call your manufacturer in that time if there are issues.

HeartStart by Philips contact: (800) 263-3342

HeartSine 350p by Stryker contact: (800) 442-1142
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