Standby Request Form

Request an ambulance to standby for your next event
Please complete the following form. When you are done, click the submit button, and we will get back to you as soon as possible.

Organization Name(Required)

Billing Address

Contact Person(Required)

Phone Number(Required)

Fax Number

Email(Required)

Rates (2-hour Minimum)

ALS ($200/hour)

BLS ($150/hour)

Event Location

Location of the Ambulance Staging Area

Date of Service

Requested Start Time

Hours Requested

Name

This field is for validation purposes and should be left unchanged.

Please be advised that if the event is canceled without prior notification and the ambulance arrives on site, the promoter will be charged 50% of the requested hours.

By clicking the Submit button, I am acknowledging the requested services listed above and understand that payment is due upon receipt of the invoice.