Request for Event Medical Standby Services – Explorer – 1 Ambulance

Tell Us About Your Event

Request for Medical Standby Services

Step 1 of 3

Contact Information

Please provide your billing information and complete this form to process your event medical standby request accurately.

Name of Person Requesting Standby Services*

Title/Position

Please provide your title or position

Name of Company/Organization

Company/Organization Address*

Direct Contact Phone Number*

Alternate Contact Phone Number

Email Address*

The email address must be for the person responsible for or authorized to sign agreements.

Event Information

Tell Us About 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 select the type of medical standby services you request for your event.

How Many Ambulances

How Many Personnel

Number of Days

Please enter a number from 1 to 31.

Approximate Number of Attendees

Date

Start Time

End Time

Day-1 |Date

Day-1 |Start Time

Day-1 |End Time

Day 2 |Date

Day-2 |Start Time

Day-2 |End Time

Please Provide The Date Range of Your Event

Start Date

End Date

Please List the Day, Date, and Start Time for Each Day of Your Event

Day of The Week

Date

Start Time

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

Please Provide The Date Range of Your Event

Event Site/Venue Information

E-mail

Dispatch

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