cityofboston.gov

* required field Event Information

Name of Event: *

Date (mm/dd/yyyy): *

Start Time (e.g 10:00 am): *

End Time: *

Venue: *

Street #: *

Street Address: *

Section of City: *

Select a Neighborhood Allston Back Bay Bay Village Beacon Hill Brighton Charlestown Chinatown Dorchester (North) Dorchester (South) Downtown East Boston Fenway/Kenmore Hyde Park Jamaica Plain Mattapan Mission Hill North End Roslindale Roxbury South Boston South End West End West Roxbury

Zip Code: *

Anticipated # of Participants: *

Give a number or range (e.g. 50-75)

Age Group of Participants: *

YouthElderly
High SchoolMixed Age Groups
AdultUnknown

Desired EMS Service/program (check all that apply): *

CPR Training (available in English & Spanish) Cold Weather Safety Information
AED Training (available in English & Spanish)Health Presentation
First Aid TrainingSafety Presentation
Blood Pressure ScreeningsEducational Ambulance Tour
Car Seat ProgramHigh School EMT Course
File of Life ProgramLife and Loyalty Program
Hot Weather Safety InformationOther

Please provide a brief description of the event and the service/program you would like Boston EMS to provide: *

* required field Organization Information

Organization Name: *

Organization Type: *

Community GroupSchool
Not for ProfitCollege/University
BusinessReligious Organization
City DepartmentOther
Hotel

* required field Event Coordinator

First Name: *

Last Name: *

Email Address: *

Main Telephone #: *

Secondary #:

Fax #:

Event Contact — Fill out if different from Event Coordinator

First Name:

Last Name:

Email Address:

Main Telephone #:

Secondary #:

Fax #:

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