NO-CHARGE AMBULANCE STANDBY SERVICE
Your event must meet the following criteria to be eligible for a no-charge ambulance standby. Please check all that
apply to you event:
_____ This event is a community event where no tickets are sold, admission charged or for-profit activities held.
_____ This event is a community event for the participation of the general public with no commercial sponsor.
Name of group sponsoring event: __________________________________________________
Name, address and phone number of contact person for the event:
Type of event: ________________________________________________________________________________
Date and time of event: _________________________________________________________________________
Number of Participants: _________________________________________________________________________
Location of event or course to be followed:
(attach diagram or map if available)
Street address of event (mandatory for entry into dispatch computer):
Pertinent information to justify need for an ambulance:
Describe type of medical resources or personnel to be present for the event (excluding EMS):
Contact person at event location: __________________________________________________________________
Signed by: __________________________________
Date of request: ______________________________
Please return completed form to:
ESCAMBIA COUNTY EMERGENCY MEDICAL SERVICES
2257 NORTH BAYLEN STREET
PENSACOLA, FL 32501
FAX NUMBER (850) 595-3174
