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Mdewakanton LIFE Program REQUEST FORM

Organization Information
Organization*
Organization Contact*
Medical Director
Phone Number*
Email Address
Organization Address*
City*
State*
 Zip*
 
About the Organization*
How will the AED be utilized?*
Area and population your organization covers*
*required information

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Submitted forms will be followed-up by a phone call within 30 days of receiving the request. If you have any questions, please contact the AED Coordinator at:
Mdewakanton Emergency Services
c/o: Mdewakanton “LIFE” Program
2330 Sioux Trail NW
Prior Lake, Mn 55372
 

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