Name:
Email:
Security Code:
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APPLICATION FOR AED PROGRAM
Name of Center or Association
Venue Location (list if more than one)
Complete Mailing Address
Primary Phone
Secondary Phone
Fax Number
Email Address
Executive Director, President, etc. (Primary Contact)
Complete Mailing Address
Primary Phone
Secondary Phone
Email Address:
Number of Athletes Served (approximate)
Number of sports, activities on site (Please list)
Days & Hours of Operation of the Center or Association?
Number of weeks annually the Center or Association operates?
Number of Coaches, Volunteers, involved in your program, etc.?
Number of Coaches currently CPR/AED certified?
Projected actual location for the AED if selected?
Security for AED? Locked in Room, Concession Stand, Wall Mount?
Are you able to purchase a Wall Mount Security Box for the AED?
Yes
No
Describe location, locks, access & availabilty to where an AED would be located:
Is there an Emergency Action Plan on file?
Yes
No
Is the Emergency Action Plan currently posted for all to see?
Yes
No
Where is the Emergency Action Plan currently located?
Who will be person responsible for maintenance log of the AED?
Are you currently a member of JSMP (Jacksonville Sports Medicine Program)?
Yes
No
Please type or copy/paste list of your Board or Advisory Group Members
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