AED Program Application - North Texas Regional Advisory Council

Applicant Information

Organization/Group Name(Required)

Primary Contact Person(Required)

Title/Role(Required)

Phone Number(Required)

Email Address(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Organization (check one)(Required)

Other

Location & Community Impact

Address where AED will be placed(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Describe the community or population served by your organization(Required)

Approximate number of people served annually(Required)

Does your organization currently have funding to purchase an AED?(Required)

Yes

Please explain any financial hardship or lack of resources

NTRAC will provide CPR/AED training to your organization.

Do you agree to allow NTRAC to conduct the training and ensure staff, volunteers, or community members attend?(Required)

Yes

Estimated number of participants to be trained(Required)

Note: Scheduling of training will be coordinated by NTRAC after application approval.

Do you agree to maintain the AED in good working order, including battery and padreplacement as required?(Required)

Yes

Please identify the person(s) responsible for ongoing AED maintenance(Required)

Please include the following with your application (if available):

By signing below, the applicant certifies that:

All information provided is true and accurate.
The organization commits to participating in NTRAC-provided CPR/AED training (to be scheduled post-approval).
The organization commits to proper placement and maintenance of the AED.
The AED will remain accessible to the community as agreed upon.

Your Name(Required)

Your Title(Required)

Today's Date(Required)