Training Request Form

Training Request Form

Please fill out the form on this page to request a ground safety course or other training and we will reach out to you.

Contact Information

What agency is requesting training?*

Contact's Full Name*

Contact's Email Address*

Contact's Cell Phone #*

Phone

Work Phone #

Phone

Event/Training Request

Please select the event or training requested and list, in order of preference, 3 dates and times you would like to be considered for your class.

What event or course(s) are you requesting?*

Select or enter value

If you chose "other", what training are requesting?

First choice Date*

First Choice Time*

Second Choice Date

Second Choice Time

Third Choice Date

Third Choice Time

Service Information

Types of Providers

Select or enter value

Describe your service

Call volume, types of calls, first response, transporting service.

Will you be inviting neighboring agencies?*

Yes

If yes, list which agencies

Training Site Information

Please provide information about the training location, including the physical address, the classroom setting, what AV equipment you have, and the location and description of the landing zone (if applicable).

Classroom Street Address*

Describe the classroom setting where this training will take place (conference room, training area, etc.).*

75 character limit

AV Equipment*

Large Screen TV with HDMI

Computer

Projector

Screen

Other

If "other" was selected, please describe below

75 Character Limit

Landing Zone Information

Aircraft requested for this training?*

Yes

Is a ground ambulance requested for this event?

Yes

LZ street address*

LZ City and State*

Describe the event and describe known hazards

75 Character limit

Has DHART landed at this location before?*

Yes

Unknown

Is this LZ listed as a DHART pre-designated LZ in your town?

Yes

Would you like this LZ to be listed as a pre-designated LZ in your town?

Yes

Landing Zone Coordinator Call Sign*

EX: N-24, 34E1, Etc

Radio Frequency*

Select or enter value

Other Radio Frequency

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