Special Event Medical Coverage Request Form

All requests should be at least 14 days prior to the event.

Event Name

Event Description

Event Start and End Times

Start Time *

End Time *

Please list the dates and times you want EMS coverage on site.

Type of Coverage Requested

Ambulance & Crew ($160/hr)

Staff Only - No Ambulance ($60/hr)

Vehicle with Single Paramedic ($60/hr)

Bike Team ($120/hr)

Please have an EMS rep call me to discuss

Submitter Information

Submitter Phone Number

Submitter Email

Is the on-site point of contact different than the submitter?

Yes

On-site Contact Phone Number

On-site Contact Email

Special Instructions or Requests