Medical Stand-by Request

Step 1 of 2

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

Location of stand-by:(Required)

Location must be within the Town of Greenwich

Street Address Venue or Place

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

Time of stand-by starts:(Required)

Time of stand-by ends:(Required)

Organizational Tax status:(Required)

For Profit

Non-profit

Is this a municipal agency in Greenwich?

Yes

Number of attendees expected at event:(Required)

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

Primary Contact(Required)

First Last

Primary Contact Cell Phone#(Required)

Additional Day of Contacts?

Yes

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

Yes, this is the first year

No, we have done this before

Please provide any additional information about the event: