AED Release and Reimbursement Form
AED Liability Release
On this date, intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless Massachusetts State Soccer Association, and of its affiliates or agents representing or related to Massachusetts State Soccer Association in regards to the use of an Automated Electronic Defibrillator (AED). This release is for any and all liability for personal injury (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for the use of this AED. The undersigned further agrees to abide by all the recommendations concerning the proper use and care of the AED.
Name
First Name
Last Name
Signature
*
Date Signed
-
Month
-
Day
Year
Date
League Affiliation
Team Affiliation
If this is AED is for the league, just leave this field blank
Mass Soccer AED Subsidy Request
Mass Soccer will each reimburse you $250 towards the purchase of your team's AED. We also now offer $75 reimbursement for replacement batteries/pads.
Subsidy request type:
AED Unit
Replacement parts
Who should the check be made payable to?
*
Address where your subsidy check should be sent:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Please upload your AED receipt/proof of payment
*
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