Special Events / Community Program Stand-by Request Form

Date of Request:*

Date of Event:*

Name of Event:*

Location or Address of Event:*

Contact Person:*

Phone Number:*

Requested Arrival Time:*

Estimated End Time:*

Approximate Number of Participants:

Age Group of Participants:

Single Coverage: A single EMS provider will be dedicated to your event from the requested arrival to end time. This provider can evaluate injured or ill individuals and provide basic stabilization and coordination for transport if necessary.Full Crew – BLS: A fully staffed ambulance with 2 EMTs will be dedicated to your event from your requested arrival time to end time. These providers will be able to evaluate injured or ill persons associated with your event and provide basic emergency stabilization care, arranging for and/or providing medical transport to the hospital if necessary.Full Crew – ALS: A fully staffed ambulance consisting of either a paramedic or advanced EMT and an EMT will be dedicated to your event from your requested arrival time to end time. These providers will be able to evaluate injured or ill persons associated with your event and provide advanced stabilization care (including placement of IVs, administration of medications/fluids), arranging for and/or providing medical transport to the hospital if necessary.Alternate Post: A fully staffed ambulance consisting of a paramedic and EMT will be stationed at your event during the time requested. However, this unit will remain available to take 911 calls if needed. We can, therefore, not guarantee a crew will be present at your event for the entirety of the event. If the stationed unit is required to leave, we will make every effort to reassign another unit to your event.

Name:*

Email*

example@example.com

Billing Contact Phone Number:*

Format: (000) 000-0000.

Billing Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Comments / Special Instructions:

Who is Sponsoring this Event:

Signature*

Please drop off the complete form to our office located at 2730 12th St SW, Cedar Rapids, IA 52404. If you have any questions please feel free to contact us at 319-366-2300.

Special Events / Community Program Stand-by Request Form

Billing Information