Ems Event Registration Form

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Randolph County Emergency Services
Event Registration Form
Event Contact Information
Requesting Organization: _______________________________________________________
Address:
________________________________________________________________
Phone
(___) ______________________
Fax(___) ___________________________
Event Information
Event Date: _______________________
Event Type: _______________________________
Event Location: _______________________________________________________________
Number of Attendees: _______________________ Event Inside or Outside: _______________
Event Start Time: _______
Event End Time: _______
Age of Group: _________________
Event Description: _____________________________________________________________
____________________________________________________________________________
Event Coordinator’s Contact Information
Name:
________________________________________________________________
Address:
________________________________________________________________
Phone:
_________________________
Cell: _______________________________
E-mail Address: _______________________________________________________________
Special Instructions
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Complete by RCEMS Personnel
Date Received: ______________________ Received By: ______________________________
Approved/Denied
Reason for Denial: ___________________________________________
Personnel Covering the Event: ___________________________________________________
Submit Registration Form
Or Print and fax to 336.318.6951

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