Middlebury College EMS - Event Coverage Request Form
Organization Information
Name of Organization
*
Affiliation with Middlebury College
*
On Campus
Off Campus
Organization Type
*
For-Profit
Non-Profit
Contact Person Name
*
First Name
Last Name
Contact Person E-mail
*
Contact Person Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Information
Start Time & Date of Event
*
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Month
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Day
Year
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End Time & Date of Event
*
-
Month
-
Day
Year
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1
2
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4
5
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8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Type of Event
*
Concert
Sporting Event
Lecture/Symposium
Other
Other - Please Describe
*
How Many Attendees do you Expect?
*
Will Alcohol be Served?
*
Yes
No
How Many EMTs do you Anticipate Needing?
*
Would you like an Ambulance on-site?
*
Yes
No
What Types of Injuries do you Anticipate?
*
Addition Information on the Event
Submit
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