Request for Special Event Coverage

Request for Special Event Coverage

This form must be completed in full at least 4 weeks before the event for consideration.
After receiving your request for Special Event Coverage Form ,Durham County EMS will determine if coverage will be offered.

If coverage is offered, Durham County EMS will decide which EMS resources(s) will be used and we will provided a confirmation and an estimated cost.
Factors used to determine whether/how coverage will be offered may include: event crowd size (2,500+), risk factors for participating population, EMS access to venue (area traffic impedance), EMS availability and event impact on 9-1-1 operations.

If you do not hear from in us within one (1) week of your initial request, contact us at 919-560-8212.
Submitter Information
Event Coordinator

First NameLast Name
Title/Position
Phone Number
Please enter a valid phone number.
Phone Type

Cellular PhoneOffice PhoneHome Phone
Email
example@example.com
Event Information
Sporting Event

FootballBaseballSoccerRace (bike)Race (foot)Other
Other Event Types

AssemblyConcertFestivalRallyParadeWalk-a-thonNational Night OutPartyOther
Anticipated Crowd Size (including staff/volunteers/attendees)

< 2,5002,500 - 15,00015,000 - 50,000> 50,000
Event Name
Start Date / Time

MonthDayYear
Date
Hour MinutesAM/PM Option
End Date / Time

MonthDayYear
Date
Hour MinutesAM/PM Option
What Time does EMS need to be On Site?
Event Location
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload any maps of the course or venue are required and must be returned with this form unless the venue is a permanent.

Cancelof
Please upload flyer or brochure that was posted to advertise event.

Cancelof
On site contact name:

First NameLast Name
On-site contact phone number on day of event
Please enter a valid phone number.
Will food and beverage be sold at the event?

YesNo
Will alcoholic beverages be sold at the event?

YesNo
Please provide us with billing information for the event.
Please provide us with billing information for the event.Company/Group/Induvidual to be billed:
Tax ID/SS# (if applicable)
Billing Addess

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please let us know if we need to know any additional information about your event that you feel is important we know about.
To receive a copy of your submission, please fill out your email address below and submit.
example@example.com
Should be Empty:

Request for Special Event Coverage

Submitter Information

Event Information

Please provide us with billing information for the event.