AED Donation Application Form The Alyssa Dressler Foundation is on a mission to raise awareness about Sudden Cardiac Arrest (SCA). We are donating Automated External Defibrillators (AED) to non-profit groups where children learn and play in the Central Pennsylvania area. Central Pennsylvania consists of the following counties: Columbia, Juniata, Lycoming, Mifflin, Montour, Northumberland, Snyder and Union. Unfortunately, we are unable to donate outside of those counties. To request an AED, have the owner/director of your organization complete this AED Donation Application and email to info@alyssadressler.org. Please include your 501c3 approval letter . We will contact you if we need additional information or clarification All applications will be reviewed by the board and donations will be made quarterly. Date Organization Name Contact Name & Title EIN# (please attach 501C3 letter) Mailing address Email address Website /Facebook page Phone # Why is your organization requesting an AED? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ How many people use your facility on a daily basis? __________________________________________ How many youths will potentially be served by the AED? ______________________________________ Does your organization currently have an AED? _____________________________________________ AED Package Contains: AED with a set of adult pads Carry Sleeve Respond AD/CPR Pack Standard Wall Cabinet 3D AED Wall Sign AED/Window/Wall Decal AED Check Tag Responsibly Terms and Conditions: 1. Registration: Each new AED must be registered with: a. The AED manufacturer (instructions included with AED) b. Local EMS providers (fire, police and emergency responders) 2. Maintenance: The AED will need to be checked routinely; monthly inspections are recommended to ensure they are in proper working condition. Every three years the battery will need replaced and the pads will need replaced after each use or every four years. 3. Training: Every staff member of your organization should be trained in recognizing the signs of SCA and how to use the AED. 4. Access: Quick access to the AED is crucial to save lives. The AED cabinet must be mounted in a visible, easily accessible location. The 3D AED sign that is included needs mounted above the cabinet. If the AED will be carried with your group, it must be in its case at all times when not being used. 5. Foundation support: The Alyssa Dressler Foundation relies solely on support from generous donors and the community. We ask that you help promote the foundation in social media, newsletter, etc. 6. Notification: a. The Alyssa Dressler Foundation must be notified if the AED has been used in an emergency. b. If the organization requesting the AED disbands, we request you promptly return the AED to the Alyssa Dressler Foundation. By signing below, you agree to the terms and conditions listed above: _____________________________________________________________________________________