Event Request Form

Please fill out the form below with all information available

Event Information

Name Of Event

City/Location Of Event

Estimated Number Of Attendees

Type Of Event

Address Of Event

Street Address

Street Address Line 2

City

State/Province

Postal/Zip Code

Special Considerations

This will be a outdoor event

There will be high risk activites at this event where injuy is more likely

Alcoholic beverages and other substances that may impair individuals will be offered or accessible

This is a predominantly youth event where the majority of attendees will be under the age of 18

This is a predominantly senior event where attendees may have special medical considerations

Other

Start Date

End Date

Services

EMT

Paramedic

Set Medic

Nurse

CCO

Scuba Rescue Diver

Rapid Antigen Tests

Rapid PCR Tests

Lab-based PCR Tests

Number Of Personel Needed

Additional Equipment Request

AED

Medical Station(s) - Tent, Chairs, Table

Additional Information

We'll Be In Touch Soon!

Address

4145 Cornell Rd

Agoura Hills, CA 91301

info@eventmedservices.com

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