Automated External Defibrillator (AED) Request Form

This form allows organizations to request an Automated External Defibrillator (AED). All requests will be reviewed based on need, eligibility, and availability. Please complete all sections. A County staff member will contact you after your application is reviewed.

Name of Organization

Type of Organization

Nonprofit

Government

School

Youth Sports

Other (please describe)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Name and Title/Position

Please Explain Why Your Organization/Location Needs an AED

Contact Email Address

Confirm email

Contact Telephone

Contact Address (if different from above)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Proposed AED Location (Building/Facility Name) and Description of Location e.g. gymnasium, lobby, office, etc...

Is the Site Open to the Public?

Yes

Will Staff/Volunteers be Trained in CPR and AED Use?

Yes

Connect me with a representative for training

Do You Have an Existing Cardiac Emergency Response Plan (CERP)

Yes

No, but willing to meet with a representative to get one in place