Standby Request and Service User Information Standby Request and Service User Information Name / Title of Event * Today's Date * Date of Event * Start Time * 121234567891011 : 0030 AMPM End Time * 121234567891011 : 0030 AMPM Event requires the following level of service: * DEDICATED (Event requires that EMS be committed to the event throughout the time listed)NON-DEDICATED (Event does not require that EMS be committed throughout the event Standby medical services are for... * Participants only Spectators only Both No-Charge Exemption Your event must meet the following criteria to be eligible for a no-charge EMS standby. Please check all that apply to your event. No-Charge Exemption This event is a community event where no tickets are sold, admission charged or for-profit activities held. This event is a community event for the participation of the general public with no commercial sponsor. Requested resources/prices (check all that apply) * Ambulance (ALS) $125/hr Ambulance (BLS) $110/hr EMT w/BLS equip $35/hr ATV (2 EMT's) $90/hr Paramedic w/ALS equip $45/hr 1st Aide station - (trailer w/2 EMT's) $60/hr Event Special Package #1 - No Ambulance (3 EMT's, ATV and 1st Aide trailer) $115/hr Event Special Package #2 - No Ambulance (4 EMT's, ATV and 1st Aide trailer) $150/hr If multiday event, please list specific times and dates: 0 of 500 max characters Organization Name/Service User Entity Type * Corporation Not-For-Profit Governmental OtherOther Are you charging Admission for the event? * Yes No Primary Contact Person's Name * Primary Contact Person's Name First Name First Name Last Name Last Name Primary Contact Email * Mailing Address (For Billing) * Mailing Address (For Billing) Mailing Address (For Billing) Mailing Address (For Billing) City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Zip Code Phone Number * Phone Number 2 (If Different) Agreement THIS AGREEMENT, entered into this [140] by and between Sumner County Emergency Medical Services, (SCEMS) and [128] (SERVICE USER). WHEREAS, "SERVICE USER" is desirous of contracting for Standby EMS services; and WHEREAS, "EMS" is willing to provide such services under the terms set forth herein; NOW, THEREFORE, it is agreed: "SCEMS" Agrees to provide the above service(s) to the "SERVICE USER" named above for the dates, times, and locations specified in the standby request information above. Sumner County Emergency Medical Services, Standby Services are subject to the availability of off-duty crews and spare ambulance units. In addition, even if a "SERVICE USER" requests and agrees to the conditions of Standby Services, certain extreme, catastrophic, or immediate life-threat emergencies may still require "EMS" to diver the technicians/ambulance assigned to the Standby. If this occurs during a scheduled Standby and a lapse of on-site "EMS" coverage occurs, fees associated with that time frame will be waived. Upon completion of Standby Services, "SCEMS" will bill "SERVICE USER" for all costs associated with this agreement and "SERVICE USER" agrees to pay all fees within 30 days of invoice receipt. "SCEMS" reserves the right to refuse any Standby Services Agreement submitted by "SERVICE USER" less than 72 hours prior to the start time. Nothing herein shall be construed to create a higher standard of care on the part of "SCEMS" than generally recognized under the laws of the State of Tennessee for "SCEMS" services. The charges provided for herein reflect only those charges associated with making "SCEMS" services more readily available to the "SERVICE USER". The normal charges for the care and transportation of patients will be the responsibility of the patient. IN WITNESS WHEREOF, the parties hereto have executed this agreement on the date first noted above. "SERVICE USER" Representative * "SERVICE USER" Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank. Δ
