To request an ambulance for on-site standby at your community event or activity, please complete the following form. When complete, be sure to print a copy for your records.

For dedicated standby fees, please refer to the fee schedule menu on the Ambulance Home Page.

Please select ONE of the following types of standby:
*

Public Relations Standby: I understand that the Ambulance is not a dedicated unit for the scheduled activity or even and will remain available for, and may be subject to, public call. There is NO FEE for this standby.

Dedicated Unit Standby: I request that an ambulance be dedicated to the event or activity that is not subject to public call. By checking this box, I understand that this unit comes WITH A FEE to be billed to the name and address below for payment.<br>

Date of Request:*

Community Activity or Event:*

Location of Event/Activity:*

Date of Event/Activity:*

Time of Event: The exact time period for the standby.*

Please Provide a brief description of the Event/Activity:*

Contact Name:*

Street Address:*

City:*

State:*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:*

Phone Number: 000-000-0000*

Signature Verification:*

By checking this box, I verify that all of the information is correct and accurate and agree to pay any fees, if applicable, for services provided.