MIKEY Application – Location

Organizations can apply for a MIKEY using the form below. If you are the physician or parent of a child in need of a MIKEY, please use the application here.

Please note that The Mikey Network can only accommodate so many defibrillator requests. Once we receive your application, we will consider it carefully and contact you regarding the feasibility of placing a Mikey in your location.

First Name
Last Name
Address
City
State/Province
Postal Code
Country
Phone
Email
Organization Type
Company
Department, Industry, or Charity#:
Number of	MIKEY Units (defibrillators) Requested
Location #1
Location #2
Location #3
Location #4
Summary	Please provide a brief summary of the aims and objectives of your organization. As a member of The Mikey Network, please also list or outline any fundraising events, sponsorships, and/or educational programs you are interested in organizing to further promote The Mikey Network.