Operational/Safety Orientation Request Form Question Title 1. Organization information Organization Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * County Question Title 2. Contact person Name * Title Phone Number * Question Title 3. Contact person e-mail address Question Title 4. Contact person and phone number for day of event Question Title 5. Event location - include address and description of landing zone if aircraft is requested Question Title 6. Event date and time Date and time Date Time AM/PM - AM PM Question Title 7. Is a delay acceptable? No delay is acceptable Delay of up to 1 hour is acceptable Delay of up to X hours is acceptable If you chose "delay of X hours" above, please indicate hours here Question Title 8. Has MedEvac attended this event in the past? Yes No If yes, please indicate date below Question Title 9. Type of organization EMS/Ambulance service Fire/Rescue Squad Law Enforcement Hospital School/Education Community/Civic group Other (please specify) Question Title 10. Expected attendance Question Title 11. Type if request Aircraft visit only Classroom presentation - no aircraft Classroom presentation and aircraft visit Visit by your group to a MedEvac base (disregard items 1 and 2 on the next page) Other (please specify) Next