Emergency Medical Services
Special Event Requests and Outreach
Name:
*
First Name
Last Name
Company/Agency:
*
Division:
*
Please Select
Hazleton
Pocono
Phone Number:
*
Format: (000) 000-0000.
Email:
*
Event Title:
*
Event Type:
*
Community Festival
Health Fair
Run/Walk
Street Fair
Touch a Truck
Trunk or Treat
Other
Event Date:
*
-
Month
-
Day
Year
Date
Event Start Time:
*
Hour Minutes
AM
PM
AM/PM Option
Event End Time:
*
Hour Minutes
AM
PM
AM/PM Option
Event Address/Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of EMS Request:
*
EMS Support for Event ALS or BLS
EMS Presentation
Community Discussion
Other
Anticipated number of guests/participants:
*
Are there other services attending?
*
Yes
No
Comments:
*
Submit
Should be Empty: