2. 
3. Heart Safe Community AED Registration
   Make your community a SAFER place to live, work, and play by being prepared to reduce the number of deaths and disabilities associated with sudden cardiac arrest.
5. How does it work?
   The Blaine Police Department wants to connect with community partners and business owners who have an AED on site that could be used in the event of someone experiencing cardiac arrest. The Blaine Police Department maintains a database of AED’s that are located around the community and publishes that information on a map. The list is reviewed and updated on an annual basis.
7. How do I participate?
   If you choose to participate, start by registering your AED with the police department. Participation is voluntary and you can end your participation at any time. Only public information will be published, that information is limited to the building address and whether or not the AED is publicly available or has restricted access. If the AED is removed at any time, we ask that notification be sent to the police department so the public list may be updated.
9. Why should I participate?
   With your help, the Blaine Police Department is raising awareness that AED’s are in many of the businesses and public spaces in the city. Early defibrillation is a critical link in the chain of survival for someone that is experiencing sudden cardiac arrest. By sharing with the public the location of your AED, you are helping the community of Blaine reduce the number of deaths and disabilities that are caused by sudden cardiac arrest.
11. First Name*
12. Last Name*
14. Address*
16. City*
17. State*
18. Zip Code*
20. Primary Phone Number*
21. Email Address
25. Number of AEDs
26. Where are your AEDs?

    1. Front door
    2. Back door
    3. Easte side of building
    4. West side of building
    5. North side of building
    6. Southside of building

    1. Breakroom/Lunchroom
    2. Manager's office
    3. Security office
    4. Lobby
    5. Hallway
    6. Other (please specify below)
28. Other
    (please specify below)
30. Is the AED
    -- Select One --Available in a public space?Restricted access or only accessible by employees or keys
34. Electronic ("signature")*
    By typing my name in this form I certify that I am voluntarily providing information for the community program known as Heart Safe Community through the Blaine Police Department. I realize if sudden cardiac arrest occurs at my address, people will want access to the AED on site. I understand my name and personal contact information will be maintained in a secure database as a part of the program, which is classified as non-public or confidential information. I understand the address of the building where the AED is located, and if it is in a public or restricted area, will be published. I may ask to be removed from Heart Safe Community program at any time, and have my information removed from the database.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field