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Event Request Form

2. Emergency Medical Services Event Request
   The Events division of East Baton Rouge EMS provides several services to the citizens of our community. Please utilize this form to request coverage for your event.
4. Date and Time of Event*
   Date and Time of Event

   Date and Time of Event
6. Name*
7. Email
9. Telephone*
10. Alternate Telephone
12. Event Type
    -- Select One --Media StoryMedical StandbyParade"Perry" Safety TalkPublic SpeakingRecruiting EventUnit DemonstrationOther
13. City
15. Event Location*
    Name of business or Address
17. Please give a brief description of the event. Date / time, location, and how many people expected to attend.
19. Note
    Please note that the submission of this form does not guarantee approval. Certain large public events may take priority over private events. A fee may be charged for non-charitable private functions.
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field