Health Fairs/Touch a Truck Request Type of Request*Ambulance and Full CrewEMT Only (no ambulance)What kind of event are you planning?Date of Event? Time requesting an ambulance to be on site? : HH MM AM PM Time requesting an EMT to be on site? : HH MM AM PM Anticipated time the event will end? : HH MM AM PM Address of event? Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Approximate number of attendees at the event?Will there be alcohol served?YesNoContact Person Name* First Last Best contact number?*Cell phone number?
