EMS Event Coverage Request

Submitted by ichoyle on Fri, 10/11/2024 - 11:50

Please complete this form to request EMS coverage for an athletic or special event

All fields below are required. *

Indicates required field

Event Name

Start Date and Start Time

Event End Date and End Time

Event Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Number of Attendees

Event Description

Event Contact Name

First

Last

Event Contact Number

Event Contact - Day of Event

First

Last

Event Contact Cell Phone

Event Contact Email

Event Billing Contact

First

Last

Event Billing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

I understand that this is a request for service only and event coverage is not confirmed until I have received details from Guilford County EMS.

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