Racing Heart SCC AED Funding Application
Program Summary

Racing Hearts targets under-served communities and at risk areas where the greatest risk of sudden cardiac arrest (SCA) exists. We strongly believe in following guidelines established through evidence based research which supports placing multiple AEDs in one site. AEDs are life saving heart defibrillators which along with CPR increases one's survival.

Your organization may be selected by the Racing Hearts Santa Clara County (SCC) AED oversight committee which meets approximately four times a year. Any organization who meets the criteria relative to high risk, low income and/or underserved populations can apply. This application is specific to the SCC matching 1:1 grant and funds may only be used within the Santa Clara County. Funds pay for equipment, supplies, and maintenance for the first three years (additional supplies will not need to be purchased for the first five years).

www.racinghearts.org
Organization: *
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Application Date *
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Organization Type (check all that apply) *
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Address: *
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Contact Person: *
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Population at this site (check all that apply): *
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Contact Person - Job Title: *
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Phone Number: *
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Alternative Phone Number:
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Email: *
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Fax Number:
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Website:
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Facebook:
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Protection and Underserved Numbers: *
State how many people the AED(s) being requested will protect on a yearly basis. Also, please estimate the percentage of underserved population the AED(s) being requested will assist.
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Specific Needs: *
1. The # of AEDs requesting (includes a wall case, youth/adult capacity, and fast response kit): (unsure is ok)
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2. Will the AEDs be stationed in Police Cars?
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3. The # of wall cabinets and wall signs: (unsure is ok)
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4. Tell us the number of people onsite who are CPR/AED trained?
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5. Do you need a Software Management Program?
Beginning Jan. 1, 2016, AEDs are required to be checked 4 times a year. (unsure is ok)
California Laws relative to AEDs:
By applying for this grant, your organization will comply with the State of California laws relative to AEDs. Specifically, your organization will follow SB658 and Title 22 which ensures that a CPR/AED orientation is completed yearly with your staff and employees, including information describing Sudden Cardiac Arrest, your emergency response plan and proper use of an AED. Your organization will ensure that the AED(s) are inspected quarterly and results documented. Will advice your vendor of any needed maintenance and/or parts for the AED in a timely manner (pads require changes every 28 months and ordering a back up battery every 4 years). In case of an AED use, your organization will contact the vendor to download the AED's data, to complete an AED use form, and to sent it to Racing Hearts and the county of placement. Your organization will monitor and maintain the AED and related equipment for five years after it's installation. Non-compliance with any of the above statements, if not corrected, may result in removal of the AED(s) and all related equipment.
By typing your name below, your organization and you agree to comply with the California Laws relative to AEDs. *
Name (electronic signature), Title and Date
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