Making You ‘Heart Safe’

• AED(defib)

• Wall bracket

• Paediatric pads (used on children 1-8 years)

• Adult pads

• A certificate to display in the school

• Training sessions offered in the evening for staff members to attend

• A talk on Anti-Violence during the presentation assembly

• First Aid workshops for Years 5 & 6 after the presentation of the defibrillator

• Charity pot (for future fundraising and ‘pass it on’ opportunities for the next school)

Details About You

School Name*:

School Address:

Contact Name*:

Your Email Address*:

Your Phone Number*:

I am: (Teacher / Staff etc)*

School Details

Age Range*:

Number of Pupils*:

Number of Staff*:

Web Address:

School Phone Number*:

Reason for the Defib / Talk:

Where is your nearest Defib, if known:

How would you Support our Foundation?:

Any more information to would help your nomination for a Defib:

Details About You

Club Name*:

Club Address:

Contact Name*:

Your Email Address*:

Your Phone Number*:

I am: (Manager, Committee, Parent, etc)*

Club Details

Age Range*:

Number of Players*:

Club Web Address:

Club Phone Number*:

Reason for the Defib / Talk:

Where would you store the Defib:

Would you use it for away games too:

Where is your nearest Defib, if known:

How would you Support our Foundation?:

Any more information to would help your nomination for a Defib:

Details About You

Business / Organisation Name*:

Full Address:

Contact Name*:

Your Email Address*:

Your Phone Number*:

Who am I to the Business/Organisation*:

Other Details

Nature of business/organisation:

Web Address:

Opening Hours:

Where would you store the Defib:

Where is your nearest Defib, if known:

How would you Support our Foundation?:

Any more information to would help your nomination for a Defib: