Medical Standby Request Type of Request*Ambulance and Full Crew $100/hrEMT Only (no ambulance) - $50/hrWhat kind of event are you planning? Date of Event? MM slash DD slash YYYY Time requesting an ambulance to be on site? : Hours Minutes AM PM Time requesting an EMT to be on site? : Hours Minutes AM PM Anticipated time the event will end? : Hours Minutes 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? Yes No Contact Person Name* First Last Email Address* Best contact number?*Cell phone number?
