Medical Services Event Request Form

    Please provide the requested information and complete this form in its entireity for accurate processing of your event planning request.

    * denotes a required field

    Client Information

    *First Name

    *Last Name

    *Your Cell Phone Number

    An Alternate Contact Number

    *Your Email Address

    Event Information

    *Type of Request

    *Date of Event
    [datetime* datetime-770 date-format:mm/dd/yy time-format:HH:mm]

    *Type of Event

    *Start Time

    *Set-Up Time

    *End Time

    +Please include your set-up and breakdown time when requesting a venue. We require 15 minutes prior to the start of the first game to prep. Rain outs and delays will have a charge applied.

    *Event to Take Place (city/state)

    *Number of Anticipated Guests

    Set-up Information

    *Seating Style
    Inside and a table with 2 chairs with be provided by siteOutside and a pavilion is available for seatingOutside, Canopy tent provided with a table and chairsPark, open fields bring your own chairOutside, bleachers provided or bring chair

    Number of Chairs

    Number of Tables

    *Training Room and ability to use it
    YesNo

    *Ice Provided
    YesNoIce MachineOther

    Outside Event
    Covered sheltered area10x10 tentOpen airOther

    *AED's (Automatic External Defibrillator)
    YesNo1-23-6Inside/Outside GymsLobbyAuditoriumAdults pads onlyAdult and Pediatric padsBatteries up to dateOther

    *Courts
    YesNo1-23-45-6More than 1 locationOther

    *Fields
    YesNo1-23-45-6More than 1 locationPinwheel style 4Other

    *Hockey Rinks
    YesNo1-23-45-6More than 1 locationOther

    Special Instructions

    Media

    Choose All That Apply

    Audio Provided Onsite
    Podium (w/Mic)Handheld MicOther

    Visual Provided Onsite
    LaptopProjector & ScreenDVD/VCRTV/DVDExtension CordsSmart TVOther

    Please note, additional fees may apply. Equipment/staff may be limited depending on the venue and event demands.

    Food Available Onsite

    Options
    No food onsiteAvailable for purchaseBeverages OnlyCatered InOther

    Special Instructions