Request an AED from the John Mack Foundation

Request an AED from the John Mack Foundation

 

Please complete this form to request an AED from the John Mack Foundation. You will receive a copy of the form by email once completed and submitted.

Please note: you can request multiple AEDs but most times we donate one at a time so we can reach more organizations. You can submit another request at a later date and we will do our best to fulfill it. Fulfillment depends on the number of organizations that we receive requests from and the amount of funds we raise in a given year.

We also work with organizations to provide AEDs at our cost when organizations have money to purchase an AED or need multiple AEDs.

If you have an AED and are unable to replace its expired battery and/or pads, please note the hardship circumstances below.

 

Name (required)

Email address (required)

Phone

Organization's name (required)

Organization's address (please include street, city and state) (required)

Organization's county (required)

Is this a non-profit organization?
 yes no

Number of members in your organization

Does your organization currently have any AEDs?
 yes no

Does your organization have any funds to use towards the acquisition of an AED?
 yes no

If yes, how much?

Has your organization previously contacted the John Mack Foundation for assistance?
 yes no

Has your organization previously received assistance from the John Mack Foundation?
 yes no

If yes, please explain what the John Mack Foundation provided:

Explain what sports or physical activity occurs at your facility; are there high-risk organization members or visitors to your facility? (required)

Explain AED location considerations: how access to the AED will be handled; whether it will be available after hours; whether it will be available year-round (required)

Explain your need for an AED (required)

Provide the correct answer before submitting - this question is to prevent spambots from submitting entries (required)
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