Paramedic Standby Request for Special Events
Event Name *
Your answer
Event Date *
MM
/
DD
/
YYYY
Start Time of Event *
Time
:
End Time of Event
Time
:
Number of People Anticipated at Event *
Your answer
Event details, including special needs of attendees, risk of injury, languages spoken, etc... *
Please enter any additional information that we should know.
Your answer
Day of Event Information
Where should the paramedics report? *
Your answer
Who should the paramedics report to? *
Your answer
What is their cell phone number? *
Your answer
Name of Contact *
Your answer
Contact Street Address *
Your answer
Contact Cell Phone *
Your answer
Business Phone *
Your answer
Contact Email Address *
Your answer
Billing Information
Billing Name *
Your answer
Billing Address *
Your answer
Fees & Agreement
Fees: There will be fixed rate of $190.00 per hour for two paramedics to staff your event. In addition to the hours(s) of your event, there is a mandatory charge for the hour prior to the event and the hour following the end of the event.

Please understand that this is a request for paramedic standby and is not a guarantee of service. Requests will be filled on a first come, first served basis for the date and time requested. You will be contacted within five business days regarding your request.

By signing below I agree to the terms and fees of this request to provide paramedics to standby at special events.
Request Submitted By *
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