General Event Medicine Request Form

General Event Medicine Request Form

Event Date

Event Name

Completed by:*

Who is completing this form?

Completed by's Email*

Your email will be used if we have any additional questions about scheduling this event. You will also receive a confirmation email when this event is added to our schedule.

Do you need a quote for this event?*

Yes

Event Location

Medical Team Arrival Time*

This is the time you want our medical team to arrive.

Select

Gates or Doors Open

This is when patrons will enter your venue or if you do not have gates when you anticipate your patrons to start arriving.

Select

Event Start Time

Select or enter value

Anticipated Medical Team Release Time*

This is the time that the medical team should be released by.

Select

Anticipated Attendance

How many patrons are expected to be at this event?

Select

Requested Services*

What services are you specifically requesting? You can add additional AEMTs and Medics below.

Select

# of AEMTs*

# of Paramedics*

# of Supervisor(s)*

We require that any event that has 5 or more team members requested must include 1 supervisor. The 5th person can be the supervisor.

Event Details

What additional information do we need to know in order to appropriately staff your event? (e.g.majority of patrons are kids, special needs, or geriatric)

Onsite Event POC*

This is the point of contact that we will contact the day of the event for the fine details. Unexpected things can occur during events and we like to have the ability to contact someone onsite who can help us work towards a solution.

Onsite POC Phone #*

Please provide the phone number of the point of contact for the day of the event.

Phone

Attach any necessary documents here:

Drag and drop files here or

Send me a copy of my responses

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