General Lucky Hearts Application

Thank you for nominating a Mecklenburg County organization or individual to receive a free AED donated by the Mecklenburg Medical Alliance and Endowment and a CPR/AED awareness training class taught by MEDIC.

Please complete all information below. Remember, not all nominees will be chosen to receive a donated AED and a free awareness training class. Each business has to meet certain criteria (listed below) and must agree to hold 2 (1½ hour) awareness courses with MEDIC (up to 50 employees – 25 employees in each class) and must display the donated AED by professional guidelines.

To be considered, an organization or individual should have one (or more) of the following:

A demonstrated need for an AED (a place where a cardiac arrest is likely to occur)
Cannot afford an AED
Already has an AED, but did not receive CPR/AED awareness training for their organization and have not clearly posted their AED system

Nominated Organization *

Main Contact's Name *

Title *

Day Time Phone *

Evening Phone *

Street Address *

City *

State *

Zip *

Type of Business *

Non-Profit *

Number of Employees *

Does the nominated business own an AED? *

How Many? *

Did an AED supplier professionally install their equipment? *

Has the nominated business offered CPR/AED training for their employees? *

Was training mandatory? *

Why or Why not? *

Is the nominated business willing to hold 2 (90 minute) CPR/AED awareness training session during business hours? *

If not held during business hours, when would a training session likely take place? *

Nomination Recommendation *
Briefly, please explain why the nominated company should receive a donated AED and free CPR/AED awareness training.

Nominator Name *

Phone *

Street Address *

City *

State *

Zip *

Employer *

(*) denotes a required field.