AED Loaner Request Form
Please complete this quick 15 question form to request a loaner AED from Richmond Rescue!
1. Name of individual: *
Your answer
2. Name of group: *
If requesting for a family/individual event provide name of individual or event, i.e. "Smith Family Reunion"
Your answer
3. Phone number: *
Your answer
4. E-mail address: *
Your answer
5. Street Address: *
Your answer
6. City, State and Zip: *
Your answer
7. First date of event: *
MM
/
DD
/
YYYY
8. Last date of event: *
If event is a single day, enter same date as as above
MM
/
DD
/
YYYY
9. Describe the event you are requesting the AED for? *
e.g. concert, little league game, family reunion, etc.
Your answer
10. Location of event: *
Include street address and town. If occurring at a landmark or named facility please include (i.e. Richmond Volunteer's Green)
Your answer
11. Will this event be indoors or outdoors? *
12. Estimate how many people will attend this event: *
Your answer
13. Are you currently CPR/AED certified? *
If you are not, we are happy to set up a CPR certification training with you. We are offering our CPR courses for 50% off for users of our AED Loaner Program for up to three people from your organization! Please note in the "additional information section" if you would like to set up a CPR certification.
14. Any additional information you wish to provide:
Your answer
15. How did you learn of this program? *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Richmond Rescue. Report Abuse - Terms of Service - Additional Terms