VIFEMS Medical Coverage Request
Please select the island or region you are applying from
*
St. Thomas
St. John
St. Croix
Requests may be denied if not submitted at least two weeks before the event.
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I understand
Name of Organization:
Type of Event:
Contact Person:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Location:
Date(s) of Event:
-
Month
-
Day
Year
Date
Time of Event:
Hour Minutes
AM
PM
AM/PM Option
Expected Number of Participants:
For Emergency Responders, the following will be provided by the Organization:
Bathrooms
Meals
Non-Alcoholic beverages
Other
If other option was selected please fill here:
Other Emergency Response Agencies Requested:
VIPD
St. Thomas Rescue
St. Croix Rescue
DPNR
Other
VIPD Contact Person:
Please fill if "VIPD" option was selected above
St. Thomas Rescue Contact Person:
Please fill if "St. Thomas Rescue" option was selected above
St. Croix Rescue Contact Person:
Please fill if "St. Croix Rescue" option was selected above
DPNR Rescue Contact Person:
Please fill if "DPNR Rescue" option was selected above
Other Organization(s)/ Contact Person & Phone Number:
Please fill if "Other" option was selected above
Request Approval Status:
Request Approved
Request Denied
Reason:
EMS Chief Signature
Date forwarded to SRT Leader:
-
Month
-
Day
Year
Date
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Should be Empty: