AED Play Safe Project

Organization Application

"*" indicates required fields

Name of Organization*

Type of Organization*

Name of Person Completing Application*

First Last

Role at the Organization*

Name of Person in Charge at the Organization*

First Last

Role at the Organization*

Phone

Email*

Do you prefer phone or email communication?*

How many AEDs are you requesting?*

For what purpose will you be using Play Well Play Safe's support?*

Why should we provide you with our support? Please let us know how it's a worthy and worthwhile cause.*

Instruction on how to use the AED will be given on site when the equipment is delivered. However, we do offer classes and could give a class on it to your students or staff as well. Is this something you’d be interested in?*

Name

This field is for validation purposes and should be left unchanged.