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HWS EMS Standby Request form

 

Contact Information:

Full Name:

Phone Number:

Campus Mailbox:

E-Mail:

Department:

Event Information:

Name of Event:

Exact Location of Event:

Brief Description of Event:

Date(s) of Event:

Hour(s) of Event:

Number of Expected Attendants:

Number of Event Staff:

Any Known Medical Conditions:

Requested EMS Response:

Date(s) of EMS Presence:

Hour(s) of EMS Presence:

Number of EMTs needed:

Known Risks at Event:

Training/Equipment Required:

Ambulance Needed on site:

Is Advanced Life Support required?

Special Instructions/Other Important Information:

 

CONTACT

Darnell L. Pierce HON'13
Assistant Director of Club Sports
Phone: (315) 781-3869
E-Mail: clubsports@hws.edu