WPI EMS: Request for Medical Staffing
Thank you for reaching out to us in order to provide on-scene medical care for your event. Please fill out the following form in as much detail as you can to better prepare us to staff your event. If you have special concerns or needs please complete this form and then contact the WPI EMS officer board directly at ems@wpi.edu to discuss further arrangements.

Please note: we cannot guarantee staffing for requests with less than 7 days of advance notice. If we are able to arrange staffing in this circumstance, you may be charged a late fee of up to $10 per day.

Last Name *
Your answer
First Name *
Your answer
Event Information
Note: If your event spans two days (an overnight and/or multiple-day event), please email us directly at ems@wpi.edu for special arrangements.
Demographic Information
We will use this information to keep a record of the main contact for the detail request. Your phone number will only be used if there is a need to contact you during the day of the event with urgent information.
Organization / Club *
Your answer
Email Address *
Your answer
Phone Number *
Format: (000) 000-0000
Your answer
Name of Event *
Your answer
Event Times
Please note: Try to be as accurate as possible with both the event starting time and the event ending time. EMS is paid by shift, which can be a maximum of 5 hours. If EMS is held overtime and the last shift then exceeds 5 hours, an hourly fine of $15 for EMT level or $11 for EMR level may be incurred.
Start Time *
MM
/
DD
/
YYYY
Time
:
End Time *
MM
/
DD
/
YYYY
Time
:
Location *
Approximate Number of Attendees *
This refers to the maximum number of people in attendance at the same time. Please consider your estimate carefully. Your approximation ensures we have an adequate level of on-site personnel to respond to any medical emergencies which may arise. Protocol dictates 1 EMS personnel to every 100 people, usually capped at 4.
Your answer
Nature of Your Event *
Emergency Medical Responder ("EMR") is the basic level of medical care. Cost is $55 per person per shift. Emergency Medical Technician ("EMT") is the advanced level of medical care. Cost is $75 per person per shift.
Target Population
If applicable, please let us know who you are expecting to attend and/or participate in your event. We will use this information to best prepare for medical events specific to certain populations.
Billing
There will be a charge for any event WPI EMS staffs. Our rates are based upon a number of factors including but not limited to the: level of care required, number of attendees, and duration of the event. You will be made aware of the cost for our staffing via email after you complete this form but before an official commitment is made.

If you select the first option, a charge will be placed on your account by the WPI Police Department after the day of your event. If you select the second option, you may write out a check to WPI EMS and hand deliver it to the WPI Police Station in the basement of Founders Hall. We require that the check is provided to WPI Police at least 5 days prior to your event.

We are only able to regularly process payments these two ways. If neither option works for you please contact us directly at ems@wpi.edu for alternative arrangements.

Payment Option *
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