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CITY OF MIAMI "PAD PROGRAM"
GRANT APPLICATION OR AED PLACEMENT
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The City of Miami is dedicated to increasing the Survivability of "Sudden Cardiac Arrest" (SCA.)
victims. Over 300,000 people from all age groups die each year due to SCA. Miami's goal is to
lower this number and saves lives within our City by assisting with the deployment of
Automated External Defibrillators (AEDs) under our Public Access Defibrillation (PAD) Program,
This application is intended for those organizations that want to become a part of the "Team for
Life" by acquiring an AED, but cannot afford the initial $2,000 cost of the AED and the
associated Training Costs of $45 per person.
Date: Requesting Organization
Location (s)
Briefly describe the type of service your organization provides to the Community:
Approximate # of individuals visiting/housed at your facility on a monthly basis:
Number of AEDs Requested: Number of separate buildings:
Briefly describe why your organization needs assistance in paying for an AED:
Briefly describe how the location of an AED at your location (s) would be of benefit to your
organization and the community:
Is your organization currently utilizing AEDs at the same location(s) or do you anticipate
receiving any AEDs through any other program?
If you are receiving funding from other sources for other projects and would like to list them as
a reference, please provide the following:
Funding Organization's Name Contact Person Contact Numbers
4<eml /9- I' 6- ocN,
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411 Obligations/Commitments:
City of Miami: The City will review these applications and determine which organizations will
qualify for funding assistance and how much the City will donate to assist the applicant in the
purchase.
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Organization/Applicant: The organization/applicant will be responsible for the following:
1. Paying the difference between what the City donates and the cost of the AED.
2. Acquiring the G3 Powerheart AED from Cardiac Science.
3. Assuming full ownership of the AED unit and accessories.
4. Maintaining the AED and CPR/AED Training (anticipated maintenance and Training
includes):
a. Replacing AED pads every 2 years (cost $80 for 2 sets).
b. Replacing AED battery every 5 years (cost $300).
c. Training staff, personnel and other organization members in CPR/AED usage,
using the American Heart Association (AHA) or Red Cross CPR/AED curriculum
and guidelines. The City of Miami can provide this training at a cost or the
applicant can receive training from other CPR/AED Trainers.
d. Keeping appropriate number of staff, personnel and/or members certified in
CPR/AED usage (Re -certification is required every 2 years with AHA or every
year with the Red Cross).
e. Assuring the AED is placed in a secure, weather controlled and useful location.
f. Assuring the AED is checked weekly and PAD Program "Quarterly Inspection
Form" is properly completed and delivered to PAD Program Office on a
Quarterly and timely manner.
g. Contact the PAD Program Office ASAP after an AED event and/or for AED/PA[)
Program related issues.
5. Agreeing to donate the AED and accessories back to the City of Miami if applicant Is
unable to fulfill their commitments/obligations as described herein.
Organization/Applicant further agrees to remise, release, acquit, satisfy, waive, indemnify, hold
harmless, exonerate and forever discharge the City of Miami, Miami Fire -Rescue, its agencies,
departments, officers, employees, agents (entity and persons as appropriate) and all sponsors
and/or officials and staff of any said entity or person, their representatives, agents, affiliates,
directors, servants, volunteers and employees from any and all liability, negligence, demands,
accounts, warranties, sums of money, torts, expenses, including attorney's fees, suits, or causes
of action or rights of action, whether at law or in equity, associated with injuries or damages
from any claim by me, my family, estate, heirs or assigns from or in any way connected with
the AED.
Over a 5 year period the anticipated annual recurring costs for maintenance and training (5
people per AED) equals $182 per year.
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Insurance Requirements For A Certificate Of Insurance - (AED)
organization/Applicant: The organization/applicant will be responsible for the following:
I. Commercial General Liability
A. Limits of Liability
Bodily Injury and Property Damage Liability
Each Occurrence $1,000,000
General Aggregate Limit $2,000,000
Products/Completed Operations $1,000,000
Personal and Advertising Injury $1,000,000
B. Endorsements Required
City of Miami included as an Additional Insured
Employees included as insured
Independent Contractors Coverage
Contractual Liability
Waiver of Subrogation
Premises/Operations
Broad Form Property Damage
Incidental Medical Malpractice
II. Business Automobile Liability
A. Limits of Liability
Bodily Injury and Property Damage Liability
Combined Single Limit
Any Auto
Including Hired, Borrowed or Non -Owned Autos
Any One Accident $ 300,000
B. Endorsements Required
City of Miami included as an Additional Insured
Employees included as insured
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III. Worker's Compensation
Limits of Liability
Statutory -State of Florida
Waiver of subrogation
IV. Employer's Liability
A. Limits of Liability
$100,000 for bodily injury caused by an accident, each accident.
$100,000 for bodily injury caused by disease, each employee
$500,000 for bodily injury caused by disease, policy limit
Print Name
have read the application and attest to its accuracy.
I attest that I am legally authorized to apply and sign for the organization/applicant listed herein
ioand to enter into the obligations/commitments on behave of this organization/applicant. I also
agree to abide by the organization/applicant commitments and obligations made herein.
Signature
Title/Position Primary Contact Number
Secondary Contact Number
Witness: Date
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