Today's Date: (mm/dd/yyyy)

Billing Information

Organization:
Contact Name:
Address:
City:	State:
Office Number:	Fax:
E-mail:

Event Information

Name of Event:	Date(s) of Event:
Start time of Event:	Finish Time (approx.) of Event:
Location of event:
Expected attendance:	Age Range of Attendance:
Expected athlete attendance:	Age Range of Athletes:
Name of Contact at the event:	Cellular Number:

* Required fields

Medical Coverage Request

Staff certification level requested and number personnel requested:

* Physician(MD): Yes No    # personnel requested:

* Paramedic: Yes No    # personnel requested:

* Emergency Medical Technician (EMT): Yes No  # personnel requested:

* Registered Nurse (RN): Yes No   # personnel requested:

* Athletic Trainer (ATC): Yes No    # personnel requested:

* Request an ambulance(s) for venue site(s): Yes No (*Required staffing of one Paramedic and one EMT*)

* Request of ambulance to transport from venue site(s): Yes No

* Request for Mobile Sports Medicine vehicle (non-transport): Yes No (*Minimum of 2 staff*)

Comments/ Questions