AED Request Form-defibs4doorcounty

AED Request Form

This form is request an AED through the Defibs 4 Door County Program. The Requester will be the point of contact for delivery and ongoing requirements for the AED.

Date

Requester Information

First Name

Last Name

Phone Number

Entity

Entity - What is the name of the organiztion requesting an AED?

Responsible Party

Provide name and contact information for individual within the organization who will be responsible for the AED?

Location

Location - Where will the AED be located?

AED Model Selection

The AED models offered to government agencies are the Lifepak 1000 or Lifepak CR2 (manufacturer replacement for discontinued CR+) - All compatible with the Door County system. Note: We anticipate delivery delays that could exceed six months.

Model AED options (select one):

Lifepak 1000

Lifepak CR2

How many AEDs are you requesting?

Terms and Conditions

I understand by accepting this defibrillator I am responsible for the following: - Using the unit to support the general public Health of Door County residents and guests. - To participate and promote appropriate training in the use of the Defibrillators. - If mounted in a permanent location, to have the Defibrillator clearly visible, marked and accessible. - The ongoing costs of replacing out of date batteries and patches. (Approximately $100.00 every 2 years; Batteries available to order through the Door County Fire Chiefs Association) - In the event of required service or a factory recall the Defibrillator will be made accessible to the appropriate individuals. - In the event the Defibrillator is no longer wanted or needed it must be returned to the Door County Fire Chiefs Association. The Door County Fire Chiefs appreciates your help in this important public health partnership in Door County.

I agree to the terms & conditions