Medical Division Request
If you are in need of an Emergency Medical Services Team to standby at your event, please answer the following questions to the best of your ability.
* Required
Do you, yourself, consider this event to be a “high-liability”?
*
Yes
No
Event Name:
*
Your answer
Event Start Date:
*
MM
/
DD
/
YYYY
Event Start Time:
*
Time
:
AM
PM
Event End Date:
*
MM
/
DD
/
YYYY
Event End Time:
*
Time
:
AM
PM
How many individuals are expected to attend? (To include your event staff)
*
Your answer
Please provide a description of the event and activities:
*
Your answer
Is this event occurring on multiple days?
*
Yes
No
Point of Contact for Event:
*
Your answer
Point of Contact Phone Number:
*
Your answer
Point of Contact E-Mail Address:
*
Your answer
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