Community Defibrillator Program Registration Form

Contact information:

Name of Community Leader/Representative - Main Contact (Required)

Email Address (Required)

Phone Number (Required)

Name of Community Leader/Representative - Additional Contact

Email Address

Phone Number

Community information:

Community Name (Required)

Province/Territory (Required)

Does your community have a Giant Tiger store? Please specify the address of the nearest Giant Tiger store. (100 words max)

AED placement and need:

Describe your community's need for an AED. (250 words max)

Proposed location for AED placement (Required)

To ensure that AEDs granted through this program are accessible to the public, what specific measures will your community implement to guarantee their accessibility?

The program covers training for two individuals in each community in CPR Level C and AED through approved Canadian Red Cross Training Partners. Do you have two people willing to be trained who work or live in the same area as the AED?

Yes No

Once the three-year CPR and AED certification expires, do you have resources to help community members re-certify?

Yes No

Current AED information:

Do you currently have any AEDs in your community?

Yes No

If yes, are they publicly accessible?

Yes No

Community extra information:

We’d love to hear anything else you can share about your community! (250 words max)

By applying to this program and being selected, you consent to include yourself and your community in future opportunities, such as program reporting and marketing of the program. Do you agree?

Yes No

Do you have a connection to Giant Tiger? If yes, please explain. (250 words max)

reCAPTCHA