Black Crown VIP Coverage & Response Companion Intake
Provide VIP/client details, travel and itinerary info, coverage/conflict checks, and complete the required medical/EMS and role acknowledgments before signing.
Client, VIP, and Organization Details
Client Name
*
First Name
Middle Name
Last Name
VIP / Talent / Executive Identity or Code Name
*
Requesting Organization
*
Primary Contact Email
*
example@example.com
Primary Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Assignment Scope and Scheduling
Assignment Type
*
Please Select
Executive protection
Close protection
Travel coverage
Event coverage
Residential coverage
Surveillance support
Consulting
Other
Coverage Scope
*
Travel
Local
Multi-state
Assignment Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Itinerary
Primary Locations
Lodging and Travel Expectations
Attached to Another Unit or Team?
*
Yes
No
Chain of Command
Confidentiality / NDA Needs
Standard confidentiality
Enhanced NDA
Need review of third-party confidentiality requirements
No additional confidentiality agreement needed
Expected Role
*
Operational Risk and Environment
Hazards present
Slips/Trips/Falls
Poor Lighting
Severe Weather
Noise
Fire/Smoke
Crowded Areas
Water Exposure
Other
Alcohol or substance-related concerns
Alcohol service
Intoxicated guests
Recreational drug activity
Prescription medication concerns
Recovery environment
Other
Crowd conditions
Large public crowd
Press/media presence
Ticketed event
Line management
Unpredictable movement
Other
Minors present
Children on site
Teen attendees
School or youth event
Family gathering
Other
Weapons or security concerns
Visible weapons
Known threat concern
Security screening in place
Law enforcement coordination
Restricted access area
Other
Vehicle-related risks
Motorcade
Passenger transport
Parking challenges
Loading dock access
Road closures
Other
Air travel involvement
Commercial flight
Private aviation
Airport transfer
Baggage handling
Tarmac or ramp access
Other
Remote or isolated location factors
Limited communications
Extended response time
Difficult terrain
Limited medical access
Limited power or connectivity
Other
International travel or high-risk activities
Cross-border travel
Customs or documentation needs
High-altitude activity
Water sports
Adventure or extreme sport
Other
Coverage, Support Structure, and EMS Compact Screening
Existing medical provider coverage in place?
*
Yes
No
Unsure
Existing security coverage in place?
*
Yes
No
Unsure
Existing EMS coverage in place?
*
Yes
No
Unsure
Destination state(s) for EMS Compact travel screening
*
Will the work involve EMS clinical practice in the destination state(s)?
*
Yes
No
Unsure
Is there a licensed agency in the destination state with a designated medical director?
*
Yes
No
Unsure
Who is authorized to activate 911 or local EMS, and is the nearest hospital or urgent care plan identified?
*
Client
Security lead
Medical lead
Assigned executive support
Other
VIP Voluntary Medical and Emergency Planning
Do you have any medical conditions we should be aware of?
Yes
No
Prefer not to say
If yes, please describe any voluntary medical details relevant to planning
List any allergies or sensitivities
Emergency contact name
First Name
Middle Name
Last Name
Emergency contact phone
Please enter a valid phone number.
Format: (000) 000-0000.
Is an AED available at the location?
Yes
No
Unknown
Strict Acknowledgments and Signature
I acknowledge the scope and limitations of service
*
No medical director
No independent paramedic treatment
No diagnosis
No medical clearance
No medication administration from Black Crown stock
No IV support
No oxygen administration
No cardiac monitoring
No patient transport or medical transport
No promise to avoid emergency services activation
Emergency activation may occur
Readiness support only
Basic first aid
Emergency recognition
Coordination
Documentation
Privacy
Stable non-medical logistics unless attached to a lawful agency or medical-director structure
Additional acknowledgment or clarification
Signature and date
*
Submit Intake
Submit Intake
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