Request for Event Medical Standby Services – Explorer – 1 Ambulance

Tell Us About Your Event

Request for Medical Standby Services

"*" indicates required fields

Step 1 of 3

Contact Information

Please complete this form with your billing and event details to process your request for medical standby services for your event.

Name of Person Requesting Event Standby Services*

Title/Position:*

Please provide your title or position.

Name of Company/Organization/Promotions:

Company/Organization/Promoter Mailing Address*

Direct Contact Phone Number:*

Alternate Contact Phone Number

Email Address*

The email address must belong to the individual who is responsible for or authorized to sign agreements.

Event Information

Please provide the details of your event.

Name of Event/Promotion*

Type of Event*

Event Context/Status*

Type of Sporting Event*

Please select the nature of your sporting event.

Type of Medical Standby Service*

Please choose the type of medical standby services you need for your event.

How Many Ambulances

How Many Personnel

Will all requested ambulances have the same start and end times?*

Yes

Ambulance #1 Start and End Times:*

Start Time:

End Time:

Ambulance #2 Start and End Times:*

Start Time:

End Time:

Ambulance #3 Start and End Times:*

Start Time:

End Time:

How many days will your event last?*

Please enter a number from 1 to 31.

Approximate Number of Attendees

Date of Event:

Event Start Time:

Event End Time:

Event Dates: Start and End Times

Please provide the event dates: start and end times for both days.

Day-1 | Event Date

Day-1 |Event Start Time:

Day-1 | Event End Time:

Day 2 | Event Date:

Day-2 | Event Start Time:

Day-2 | Event End Time:

Event Dates: Start and End Times

Please provide the event dates: start and end times for both days.

Event Start Date

Event End Date

Please include the day of the week, event dates, and the start and end times for each day of your event.

Day of The Week

Event Date

Event Start Time

Event End Time

E-mail

eventservices@explorer1ambulance.com

Dispatch

(310) 537-3971

FOR SERVICE CONTACT: (310) 537-3971

Tell Us About Your Event

Contact Information

Event Information

Event Dates: Start and End Times

Event Dates: Start and End Times

Venue and Location Details:

E-mail

Dispatch

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