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2. 
3. EMS Public Relations Request
   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 attend and bring an ambulance, please fill out the form in its entirety. Incomplete form may result in your request not being fulfilled.
   
   

   For all Public Relations Events, our EMS Professionals remain in-service and are available for emergency assignments.
   
   

   If your event requires a dedicated unit that remains on site and is not subject to being called away for an emergency, then please use the EMS Standby Request Form

5. Name of Event?*
7. Type of event? (i.e., birthday party, show and tell, 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 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*
29. I understand that if a EMS unit is able to attend, they are in-service and will be available for an emergency assignment, and they may leave at a moments notice.*

    1. Yes
    2. No
30. EMS Standby Request Form Link (needed for dedicated unit)
    EMS Standby Request Form
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

* indicates a required field