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Request Event Coverage from Â鶹Ãâ·Ñ°æÏÂÔØEMS
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Name
First
Last
Email address
Phone number
Are you requesting EMT or Wellness Ambassador coverage?
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EMT
Ìý
Wellness Amabassador
Event Name
Start Date & Time
End Date & Time
Location
Expected attendance
Event type
Ìý
Athletic event
Ìý
Concert/performance
Ìý
Conference/Meeting
Ìý
Festival/fair
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Orientation/tour
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Other
Enter other…
Risk factor(s)
Ìý
Alcohol present
Ìý
Outdoor event
Ìý
High attendance (500+)
Ìý
Physical activity
Ìý
Extreme weather possible
Ìý
Late night (after 10 p.m.)
Special considerations
