PUBLIC ACCESS DEFIBRILLATOR ONLINE APPLICATION FORM

Name of Sports Club

Address of Sports Club

Your Name

Phone Number

How many people use the sports club each week?

Is the site accessible to members of the public 24/7?

Yes

Please explain why you feel your club/site would be a good venue for a public access defibrillator (PAD)?

Do you have somebody at the club who could complete a monthly online check of the PAD?

Yes

We offer free basic CPR and defibrillator training to all venues that we provide a PAD to. Is this something your club would be interested in?

Yes

If your application was successful, do you think you could run any form of fundraising events in the future to help us continue our work - Please explain?

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Note: Please fill out the fields marked with an asterisk.