Community AED Responder Enhancement (C.A.R.E.) Program Online Registration Form - EMS Quality Assurance - Seminole County Department of Public Safety

To register your AED (Automated External Defibrillator) with local emergency service agencies within Seminole County, please fill out the following online form or click here to download a printable AED registration form [PDF]. Mail printable form to Public Safety AED Coordinator; 150 Bush Blvd; Sanford FL 32773 or Fax to 407-665-5048. If you have any questions, please contact LuWayne Bradley at 407-665-5038. * REQUIRED INFORMATION
AED Owner's / Company Name:
Enter the name of the organization or individual that owns the AED
*
Select the organization or individual entity that owns the AED
*

AED Prescribing Physician's Contact Information:
Please enter the name of the physician who prescribed the AED. This physician is responsible for the appointment of an AED coordinator; development and review of policies and procedures that define standard of patient care and use of the AED; supervision of a quality improvement program, including review of response documentation and rescue data for all application of the AED; oversight of in-house and continuing AED training; providing advice regarding medical direction activities.
Physician's Name:
Street or Box Number:
City:
State:
Zip Code:	(#####)
Telephone Number(s):	(###-###-####, )

AED Primary Coordinator's Contact Information:
Enter the name of the individual who has been appointed by the physician to serve as the primary AED coordinator. AED programs primary coordinator will be responsible for a written plan and documentation of the AED maintenance program.
AED Primary Coordinator's Name:	*
Street or Box Number:	*
City:	*
State:	*
Zip Code:	* (#####)
Telephone Number:	* (###-###-####)
Email Address:

AED Equipment Information:

Date AED was installed:	* (MM/DD/YYYY)
AED Manufacturer:	*
AED Model Number:	*
AED Serial Number:	*

Where is the AED Located?
Please note: Local EMS agencies will be notified of your AED registration based on the address information entered below. Please be sure and put the address where the AED is physically located rather than your corporate headquarters or other address.
Location / Building Name:	*
Street or Box Number:	*
City:	*
State:	*
Zip Code:	* (#####)
Alarmed Locked AED Cabinet:	YesNo

Where is the AED located at the address? Be as specific as possible
*

What is your CPR/AED training status? *

Please push Submit Form button only once The form may take a minute or two to submit