* 1. Name of Organization

* 2. Physical Address

* 3. Mailing Address

* 4. City

* 5. Zip Code

* 6. EMS Administrator

* 7. Phone #

* 8. Fax #

* 9. Email Address

* 10. Radio Frequency:

* 11. EMS Administrator's Emergency Contact Number (24/7)

* 12. Assistant EMS Administrator

* 13. Phone #

* 14. Fax #

* 15. Email

* 16. Assistant EMS Administrator's Emergency Contact Number (24/7)

* 17. (Please list the contact information for your Medical Director. DO NOT list the address and phone numbers for your organization as contact info for your Medical Director.)

Medical Director:

* 18. Mailing Address:

* 19. Phone #

* 20. Fax #

* 21. Email

* 22. Radio Frequency

* 23. Medical Directors Emergency Contact Number (24/7)

* 24. RAC Representative

* 25. Phone #

* 26. Phone # that can receive text messages for reminders

* 27. Fax #

* 28. Email

* 29. RAC Representative's Emergency Contact Number (24/7)

* 30. RAC Alternate Representative

* 31. Phone #

* 32. Fax #

* 33. Email

* 34. RAC Alternate Representative's Emergency Contact Number (24/7)

* 35. Tax status of Organization:

* 36. Counties where your organization regularly provides service:

* 37. Counties with which you have a contractual agreement?

* 38. Population of your service area

* 39. Square Miles of your service area

* 40. First Responder - # of Ambulances

* 41. First Responder - Staffed 24/7

* 42. First Responder - Crew on Call

* 43. First Responder - Runs per month

* 44. Basic Life Support - # of Ambulances

* 45. Basic Life Support - Staffed 24/7

* 46. Basic Life Support - Crew on Call

* 47. Basic Life Support - Runs per month

* 48. BLS with ALS capability - # of Ambulances

* 49. BLS with ALS capability - Staffed 24/7

* 50. BLS with ALS capability - Crew on Call

* 51. BLS with ALS capability - Runs per month

* 52. BLS with MICU capability - # of Ambulances

* 53. BLS with MICU capability - Staffed 24/7

* 54. BLS with MICU capability - Crew on Call

* 55. BLS with MICU capability - Runs per month

* 56. ALS - # of Ambulances

* 57. ALS - Staffed 24/7

* 58. ALS - Crew on Call

* 59. ALS - Runs per month

* 60. ALS with MICU capability - # of Ambulances

* 61. ALS with MICU capability - Staffed 24/7

* 62. ALS with MICU capability - Crew on Call

* 63. ALS with MICU capability - Runs per month

* 64. MICU - # of Ambulances

* 65. MICU - Staffed 24/7

* 66. MICU - Crew on Call

* 67. MICU - Runs per month

* 68. RAC-D can offer assistance to its members through RAC wide projects. It can also offer advice and assistance in carrying out injury prevention activities. With that in mind please list your needs below:
Please list EQUIPMENT needed in order or priority

* 69. Do you have a plan to obtain this EQUIPMENT?

* 70. Please list EDUCATION needed (include course , training equipment and # of students needing training)

* 71. Do you have a plan to obtain his EDUCATION?

* 72. Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience)

* 73. Use the space below to provide details concerning your needs and how the RAC might assist you:

T