Welcome to The Sussex Heart Charity - formerly the Brighton Heart Support Trust

AED Grant Appplication Form

AED GRANT REQUEST

Personal Details

Title *
First Name *
Last Name *
Position in Organisation *
Name of organisation and department *
Your Email Address *
Correspondence Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Telephone Daytime *
Telephone Evening
Are you part of, or affiliated to, a hospital trust or community organisation?
How much do you plan to contribute to your grant? *The minimum required donation is £900

Responsible Person (Must be an individual with day-to-day control)

Title *
First Name *
Last Name *
Correspondence Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *
Email *

Where will the AED be located?

Full address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Telephone number at this address *
Where precisely will the AED be located? *e.g. on the outside wall next to front door

Additional information

Will the AED be available 24 hours a day? *
If you answered NO, please state the hours of availability?
Are you seeking, or have you received, funding from any other organisation? *

Publicity

It is a condition of the Sussex Heart Charity that it may publicise grants that are awarded. Please confirm that this is acceptable to you. *
Agreed
Would you consider arranging a press release, a fund-raising event, or something similar? *
Please give details: *
Does the organisation have social media? *
Please give details: *
Facebook Page name/Twitter Handle etc..

Please give as much information about why you are seeking a grant?

Include detail such as the number of customers or visitors, local population, surrounding businesses, other local organisations which may benefit *

Declaration

• I declare that the information given on this form is true and that any funds received would be solely for use on the project as detailed above.

• I agree to abide by any conditions set out by the Sussex Heart Charity in making the award.

• I agree to return all equipment if it becomes no longer possible to proceed as detailed in this application.

• I have read and understood the Criteria for Successful grant applications to the Sussex Heart Charity

Please tick to acknowledge that you have read and understood the terms of the agreement. *
Agreed
If your application is approved the named Responsible Individual will be responsible for carrying out regular checks and the ongoing maintenance of the device, including the renewal of pads and batteries *
Agreed

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank: