AED Donation Application

The Peyton Walker Foundation’s mission is to increase awareness and survival rates of Sudden Cardiac Arrest (SCA). As part of our mission, we donate Automated External Defibrillators (AED) to non-profit groups in the Central Pennsylvania region. Central Pennsylvania consists of the following counties: Adams, Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Perry, York. Unfortunately, we are unable to donate outside of those counties.

We require that our Saving Lives Partners share the cost of the AED. The value of the AED is over $2,100, but we only request a minimum cost share of $350. Please confirm that your organization has the funds available to pay this fee.

To request an AED, have a designated person of your organization complete this AED Grant Application and email a copy of your 501c3 letter and an updated 990 or financial statement to aed@peytonwalker.org.

Applications deadlines are quarterly consisting of 3/31, 6/30, 9/30, and 12/15. We will review applications the following month after applications close. We will contact you if we need additional information or clarification. A list of what is included in the donation package is on our website at peytonwalker.flywheelsites.com.

Organization Information

Non-profit Organization Name*

EIN Number*

Primary Contact*

Position or Title in the Organization*

Primary Email Address*

Is your nonprofit organization located or service Central Pennsylvania? The following counties: Adams, Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Perry, York.*

Yes

No

Is your organization a 501c3 Nonprofit?*

Yes

No

Upload 501c3 Document*

Max. file size: 300 MB.

Upload 990 or Financial Statement*

Max. file size: 300 MB.

Are you a youth focused organization?*

Yes

No

Please explain the mission / purpose of your organization.*

Organization Street Address*

Organization City, State & ZIP Code*

County*

Primary Contact's Phone Number:*

Organization / Company Website*

AED Request

Why is your organization requesting support to obtain an AED?*

Does your organization currently have an AED?*

Yes

No

If your organization has an existing AED, what is the brand and age of the device?*

Regarding the location in which the AED will be placed, how many people use the facility on a daily basis? How many hours per day? Per week?*

How many youths will potentially be served by having the AED? How many are under 8 years old?*

There is a $350 copay for our AED program. Do you have funds available to cover the copay, as well as any future maintenance costs for batteries and pads?*

Yes

No

AED Access

Quick access to the AED is crucial to the efficacy of the chain of survival. The AED should be located where it is highly visible and immediately accessible to trained lay responders and the general public.

Where and how will the AED be stored?*

If the AED will be used as a portable device, please describe how the machine will be stored when not travelling with your organization.*

AED Training

Your organization must have individuals trained in CPR/AED. The Peyton Walker Foundation offers CPR and AED training. We also recommend that a cardiac response plan is developed and implemented in your organization. For information on CPR/AED training dates and how to create a cardiac response plan, please visit our website at www.PeytonWalker.org.

Are there individuals in your organization who are AED trained? If no, what is your plan to train individuals in your organization?*

Would you like more information on CPR/AED training through The Peyton Walker Foundation for your organization?*

Yes

No

Awareness

Understanding where the AED is located and how it works is critical. We request that signs are placed on the entrance doors to your facility as well as at the location where it is stored. All members of your organization should be aware of its location and your cardiac response plan.

In the event of an emergency, please share your cardiac emergency response plan.*

What is your plan for educating your members about the location of the AED and your cardiac response plan?*

Maintenance

AEDs need to be checked routinely to ensure that they are in proper working condition. It is the organization’s responsibility to check the AED monthly and to replace the battery and pads approximately every three years. Pads will need replaced if they are used. Current replacement parts are available at PeytonWalker.org.

Who from your organization will be responsible for registering the AED with the manufacturer and with local EMS providers?*

Who from your organization will be responsible for providing future maintenance and be the AED maintenance contact for us to contact?*

Who from your organization will be responsible for the routine maintenance/monitoring of the AED?*

Foundation Support

The Peyton Walker Foundation relies on backing from the community. We ask for your support to help us spread our life saving message through presentations, community events, and local media.

How will your organization promote the AED donation to the greater community?*

Would you be willing to host a fundraising event to help us support our mission?*

Is there an event through your organization or community where we could hold CPR Demos to share more about the foundation?*

Agreement and Terms

By signing below, you agree to the Terms and Conditions of The Peyton Walker Foundation’s Saving Lives Partnership/AED Grant Program. Electronic submission is validation of signature.

Terms and Conditons*

Pay the cost share of $350 upon receipt of the AED. Register the AED with the manufacturer & with Local EMS. Inform The Peyton Walker Foundation when your contact person changes. Assure the AED will be accessible, properly stored and maintained. Assure staff will be trained and cardiac response plan will be in place. Promote the donation and The Peyton Walker Foundation through social media, newsletter, etc. Inform The Peyton Walker Foundation if the AED was used in an emergency. This donation is only for the organization requesting the AED. If your organization disbands, we request that you promptly return the AED unit to The Peyton Walker Foundation. Click the check box to acknowledge the terms and conditions.

I acknowledge the terms and conditions

Name of Applicant (Acts as electronic signature)*

Today's Date*

Non-Profit AED Grant Application