Request EMS at a Special Event JavaScript Required You must have JavaScript enabled to use this form. Please enable JavaScript and reload the page. If you cannot enable JavaScript, please contact webadmin@cityofmadison.com to provide your information. Event Information Event Name * required Date * required Start Time * required Expected Duration * required Location Location Name Location Street Address * required Unit City * required State * required - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code * required Estimated number of participants * required Map * required One file only. 10 MB limit. Allowed types: gif jpg png bmp heic heif eps tif psd odf pdf doc docx ppt pptx. Emergency Action Plan * required One file only. 10 MB limit. Allowed types: gif jpg png bmp heic heif eps tif psd odf pdf doc docx ppt pptx. Additional Information Personnel & Equipment Event radios provided? * required Yes No What channel will be used? Teams Needed * required Paramedics Ambulance EMS Walking Team UTV Ambulance Paramedics Number needed Staging location Expectation of duties Report time Ambulance Number needed Staging location Expectation of duties Report time EMS Walking Team Number needed Staging Location Expectation of duties Report time UTV Ambulance Number needed Staging Location Expectation of duties Report time Staff Briefing Briefing Time * required Location * required Event Coordinator Name * required Phone * required Alternative Phone Email * required EMS Coordinator Name * required Phone * required Alternative Phone Email * required Other Contact Information Name Phone Alternative Phone Email Billing Information Organization * required Name * required Phone * required Email * required Billing Address * required Street Address * required Unit City * required State * required - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code * required Leave this field blank JavaScript Required You must have JavaScript enabled to use this form. Please enable JavaScript and reload the page. If you cannot enable JavaScript, please contact webadmin@cityofmadison.com to provide your information. Was this page helpful to you? * required Yes No Why or why not? Leave this field blank Emergency Medical Services Ambulance Billing Collapsed Ambulance Hardship Waiver Ambulance Rates Request an EMS Report AED Library Community Alternative Response Emergency Services (CARES) Collapsed CARES Data Dashboard Community Paramedicine Emergency Vehicle Question & Answer Hands-Only CPR Medical Directors Privacy Practices Notices PulsePoint Special Event Staffing Expanded Request EMS at a Special Event Tactical Emergency Medical Services
