AED Placement Application

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AED Placement Application

Thank you for your interest in obtaining an Automated External Defibrillator (AED) through Monroe Community Heartsavers. Please complete this application in full. Incomplete applications may delay the review process.

Business Name *

Business Address *

Primary Contact Person (Name & Title) *

Phone Number *

Email *

Business Hours of Operation *

Number of Employees *

Typical Daily/Weekly Customer Traffic *

(For example, “We see about 50 customers per weekday and 100 per weekend.”)

Do you currently have any AED(s) on the premises? *

Yes

If "Yes" please specify how many and where they are located

Where do you plan to place the new AED? *

(e.g., main lobby, front entrance, hallway, etc.)

Do you currently have staff members trained in CPR/AED use? *

Yes

If No, do you plan to coordinate or request training if an AED is provided? *

Yes

Terms of Agreement

By submitting this application, you acknowledge and agree to the following:

- Proper Maintenance
You will perform regular checks to ensure the AED remains operational (e.g., checking readiness indicators and expiration dates on pads/batteries).
If maintenance is neglected or the AED is repeatedly found non-functional, Monroe Community Heartsavers (MCH) reserves the right to repossess the device.

- Public Accessibility
The AED shall be mounted and stored in the supplied cabinet, in a location where staff and visitors can quickly access it in the event of a cardiac emergency.

- Ownership & Liability
The AED and any related supplies provided remain subject to MCH’s oversight.
Your business is responsible for adhering to local and state regulations concerning AED placement and usage.

- Hold Harmless Agreement
You agree to release, indemnify, and hold harmless Monroe Community Heartsavers, its officers, agents, contractors and volunteers from and against any and all claims, damages, or liabilities that may arise from the installation, maintenance, or use of the AED.
This includes, but is not limited to, any injuries, losses, or damages that may occur during an attempt to use the AED or due to any malfunction outside MCH’s control.

- Publicity & Promotional Release

You agree that Monroe Community Heartsavers may include your organization’s name and location in press releases announcing grant recipients, may take and use photographs or videos of your business and staff for promotional and educational purposes, and may feature your organization or its representatives in marketing materials, website content, social media, and other promotional activities without compensation.

- No Guarantee of Approval
Submitting this application does not guarantee that your organization will receive an AED. All applications are reviewed based on available funding, community need, and other criteria.

Signature & Submission

By submitting this form electronically, I confirm that all information provided is accurate and that I agree to the terms of this application.

Applicant Declaration & Electronic Signature *

By submitting this form electronically, I confirm that all information provided is accurate and that I agree to the terms of this application.
Please check each box to indicate your agreement:

I certify that I am authorized to submit this application on behalf of the business or organization named above.

I confirm that the information provided in this application is true and accurate to the best of my knowledge.

I have read and agree to abide by the Terms of Agreement (including the Neglect, Accessibility, and Hold Harmless provisions).

I acknowledge that submitting this application does not guarantee approval or award of an AED.

Required

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