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2. If you feel your business or establishment meets the criteria to receive a donated trauma kit and training, then please complete the application form!

4. First Name

5. Last Name

7. Email Address
9. Address
11. City
12. State
13. Zip Code

15. Please note: Must be within the Chino Valley (Chino or Chino Hills)

17. Phone Number
19. Are you willing to place a well-mannered trauma kit in an easily visible and accessible area within your business or establishment?

    1. Yes
    2. No
21. Are you willing to receive free First Care Provider Training for most or all of your staff?

    1. Yes
    2. No
23. Are you willing to complete a free facility/risk assessment form?

    1. Yes
    2. No
25. Are you and your staff willing to sign up for the free Pulse Point phone app?

    1. Yes
    2. No

    The pulse point phone app notifies you when a life saving emergency is happening near your, so you can render immediate aid to a victim.

27. Reason for your business or establishment qualifies to receive a donated trauma kit and training.

Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field