Standby Request Form

For events requesting standby services, the ambulance or staff member assigned is dedicated to the event. If an emergency transport is needed, a separate ambulance will be dispatched to transport the patient to the hospital. If an ambulance is not available to transport the patient to the hospital, the ambulance on standby may have to transport. In that event every effort will be made to dispatch an aid unit to the standby. The time the ambulance is away from the standby will be discounted from the fee. If an aid vehicle replaces the ambulance the fee will be adjusted. The patient is responsible for the ambulance transport fee which is separate from the standby charge.

Contact Name

First Name

Last Name

Name of Event

Sponsoring Agency

Where is the event located? Where will the crew be staged? Will the crew be stationary or mobile with multiple staging areas? (Please be specific)

Phone

(###)

###

####

Date of event

YYYY

Start Time

Hour

Minute

Second

End Time

Hour

Minute

Second

Estimated number of participants

Resource Request

Ambulance with 2 EMTs ($200/hr)

First response aid vehicle with 2 responders - Non-transport ($125/hr)

First response aid vehicle with 1 responder - Non-transport ($75/hr)

Snowmobile & 1 Operator ($150/hr)

First response aid vehicle with 1 E-Bike ($100/hr)

Request waiver - Exchange for in kind services of equal value (Please include proposal in text box below.)

In order to serve your event better, our Event Coordinator will be contacting you to request additional information.

For example: Does your event have a written medical response plan?, What is your communications plan?, Do you have a patient extrication plan?, Will any special equipment be required such as snowmobiles, E-Bikes, or a wheeled litter? If you have answers to any of these questions please provide them in the text box below.

Standby Request Form

Aero Methow Rescue Service