Landing Zone Form

Mercy Health Lifeflight Landing Zone Class Form
*** IF THIS IS FOR A SITE VISIT REMEMBER TO CALL INTO THE COMMUNICATION CENTER THE MORNING OF THE EVENT TO CONFIRM ALL INFORMATION AT 1-800-241-5433***
Date*

MonthDayYear
Date
Time*

:HourMinutesAM/PM Option
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Name of Agency*
What kind of Outreach is requested*

Landing Zone Class
Number of People attending:*
Location of Event: Include Address city, state and County*
Cross Roads of Event*
Frequency of Fire/EMS to talk to*
Special Instructions & Comments did you talk to anyone prior to filling out this form?*
I acknowledge that this is a FD/EMS Sponsored event and that while applicable the venue will follow the recomendations suggested by the CDC,State of Ohio and Michigan Jursidiction for gatherings.*

Yes I acknowledge on behalf of the FD/EMS Agency.
Should be Empty:

Mercy Health Lifeflight Landing Zone Class Form