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2. Label
   THIS FORM IS NOT LIVE AT THIS TIME, AND REQUESTS SUBMITTED THROUGH IT WILL NOT BE RECEIVED BY THE CORRECT STAFF.
4. Enter your contact information below
6. First Name
7. Last Name
9. Phone Number*
10. Fax Number
12. Email Address*
14. Name of Event*
18. Name of Location

19. Location of Event

    As applicable, enter the name of the location and the street address below.
21. Address 1
23. Address 2
25. City
26. State
27. Zip Code
31. Date of Event*
    Date of Event
32. Time to start setup
    Time to start setup
    When can EMS arrive to begin setting up?
33. Time Event Starts and Ends
    Time Event Starts and Ends Start Time

    —

    Time Event Starts and Ends End Time
    Enter the start and end time of the actual event.
37. Event Details
    Please explain what our role will be at the event, or what we are expected to accomplish. Also, if there additional details or important information include that here.
38. Understand that Orange County Emergency Services will try to accommodate all requests, but if we are over scheduled we will turn away events that will place too much of a strain on our staff and resources
40. Risk Level

    Please indicate the level of risk at the events, including any particular dangers that may be present. Emergency Services will make the determination of what level of coverage (BLS or ALS) is required.

41. Cost of Coverage

    A Basic Life Support (BLS) ambulance is $90 per hour. An Advanced Life Support (ALS) ambualnce is $100 per hour.

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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field