Part Funded Defibrillators Application

Part Funded Defibrillator Application Form

Charity/Community Amateur Sports Club Name: *

Name of applicant on behalf of registering organisation: *

Contact phone number for named applicant: *

Contact email address for named applicant: *

Address of Charity or Club: *

Please confirm whether you have below £10,000 in available funds: *

Overview of the aims of the charity/club: *

Overview of who your end users are: *

How many people do you support?: *

Please outline why you would like to be awarded a part funded defibrillator: *

Where would the defibrillator be based?: *

Please outline where the defibrillator would be based, e.g. at one address or would it move between locations?

Would it be made available to the general public?: *

If you answered 'Yes - during service hours' above, please state your opening hours:

Would the defibrillator be taken outside, e.g. on activities, walks etc?: *

If so, please explain what types of activities the defibrillator would be taken to. This information helps us to advise on the best type of defibrillator for your needs.

Are you able to contribute immediately towards a defibrillator upon an invoice being sent?: *

Do you know which defibrillator you’re interested in?: *

Please confirm you have read and understood the terms and conditions *

I have read the terms and conditions, understand them and agree to them.

The terms and conditions can be found at https://www.lifesavingtraining.co.uk/part-funded-defibrillators-terms-and-conditions