Operational/Safety Orientation Request Form

Question Title

1. Organization information

Organization Name *

Address *

Address 2

City/Town *

State/Province *

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

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

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)