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Home
› SMSC Mobile Event Request Form
SMSC Mobile Event Request Form
Date(s) Submitted:
*
Month
Jan
Feb
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Apr
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Year
2011
2012
2013
2014
2015
Event Name:
*
Event Donation Purpose:
Medical Support
Command Center
Other:
Event On-Site Contact(s):
Name:
*
Office #:
*
Cell #:
Email:
*
Name:
Office #:
Cell #:
Email:
Medical Director:
Office #:
Cell #:
Time Mobile Arrive:
*
hour
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minute
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am
pm
Time Mobile Depart:
*
hour
1
2
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:
minute
00
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am
pm
Location and Address Mobile to be Placed:
*
Check Event Type:
Marathon
Bike Race
Festival
Severe Weather Rescue / Clean Up
SWAT Training
Pow Wow
Amphitheater
Communication Command Center
Number of Medics/EMT:
Requested EMS Apparatus to be provided:
Ambulance
Check Requested Equipment to be provided:
Medical Bags,
Qty.
AEDs,
Qty.
WiFi Mobile Surveillance Cameras:
(9):
- None -
1
2
3
4
5
6
7
8
9
MRX Monitors,
Qty.
Leads,
Qty.
Rehab Tent
Medical Bikes,
Qty.
LED Event Sign.
Signage to Read:
Please submit your application now. Thank you for your interest. You will receive email confirmation that your request has been received.
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