Form Center

2. 
3. EMS Standby Request Form
   Cole County Emergency Medical Services is honored you are interested in having us participate in your event. If you would like to have our EMS professionals provide medical coverage for your event. Please fill out the form in its entirety. Incomplete form may result in your request not being fulfilled.
   
   

   Please note if you require a dedicated EMS unit to remain on site for the entire event, meaning that the EMS unit cannot be in-service to handle emergency assignments, there is an hourly charge for this service.
   
   

   If you do not need a dedicated EMS unit at your event, please use the EMS Public Relations Request Form

5. Name of Event?*
7. Type of event? (i.e., football game, fair, etc.)*
9. What date and time does your event start and end?*
   What date and time does your event start and end? Start Date

   What date and time does your event start and end? Start Time

   —

   What date and time does your event start and end? End Date

   What date and time does your event start and end? End Time
11. Please provide details of your event. Include event type, target audience, average age of attendees, projected number of attendees, any special request, or special needs that our EMS professionals need to be aware of.*
15. Event Contact Information
17. First Name*
18. Last Name*
20. Address of Event*
22. City*
23. State*
24. Zip Code*
26. Phone Number*
27. Email Address*
31. I am aware that an hourly fee for a dedicated EMS unit will be charged to my organization.*

    1. Yes
    2. No
33. My request is on behalf of a non-profit community organization?*

    1. Yes, verification paperwork can be provided
    2. No
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field