Medical Stand-by Request

Step 1 of 2

Demographics

Name of organization requesting stand-by:

Name of representative requesting stand-by:(Required)

First Last

Email(Required)

Enter Email Confirm Email

Cell Phone #(Required)

Work Phone #

Mailing Address:(Required)

Street Address Address Line 2 or Name of Organization City State ZIP Code

Stand-By Location Information

Location of stand-by:(Required)

Location must be within the Town of Greenwich

Street Address Venue or Place

Stand-By Date Information

If this is a multiple day stand-by event please indicate the first and last day of the event.

Date (Start)(Required)

This Event is Multiple days

Yes

Date (End)

Stand-By Time Information

Time of stand-by starts:(Required)

Time of stand-by ends:(Required)

Are the times the same for the other days?

Yes

Time of stand-by starts (Additional Days):

Time of stand-by ends (Additional Days):

Stand-By Additional Information

Organizational Tax status:(Required)

For Profit

Non-profit

Is this a municipal agency in Greenwich?

Yes

Department or Agency

Number of attendees expected at event:(Required)

Profile of participants (ex age groups, special needs, type of athletic event)(Required)

Day of Event Contact Information

Primary Contact(Required)

First Last

Primary Contact Cell Phone#(Required)

Additional Day of Contacts?

Yes

Secondary Contact

First Last

Secondary Cell Phone#

Additional Information

Is this the first time you are having this event?(Required)

Yes, this is the first year

No, we have done this before

Date of Last Event

Please provide any additional information about the event: