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Event Medical Support Request Form

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Event Medical Support Request Form

Let our Sports Medicine Event Coverage Team help you produce a safe and enjoyable competitive event.

As part of our service, we would ask that you would contribute to the community and we would also ask you to include us in your sponsor list.

Before filling out the form at the bottom of this page, please check the below Medical Coverage Calendar for our team's availability.

Please complete and submit the request form; a representative will contact you shortly. If you have any questions or concerns, please call Sarah Foreman at 530.543.5656 or email her at sforeman@bartonhealth.org.

Event Information
Event Name: *
Event Location: *
No. of Participants (approximate) : *
Event Description: *
Event Start Date: (mm/dd/yyyy) *
Start Time: (00:00) *
Event End Date: (mm/dd/yyyy) *
End Time: (00:00) *
Does this event contribute back to a local organization? *
If Yes, how do you contribute?

Below is the staffing we can provide. You may not know numbers of staff needed at this time. We can work with you to determine your needs.
Physicians
Estimated No. of Physicians
Registered Nurses
Estimated No. of Nurses
Ambulances
Estimated No. of Ambulances
Athletic Trainers
Estimated No. of Athletic Trainers
Physical Therapist
Estimated No. of Physical Therapist
Special Notes
Contact Information
First Name: *
Last Name: *
Address:
Street Address: *
Address Line 2:
City: *
State / Province / Region: *
Phone Number: (xxx-xxx-xxxx) *
Email: *
Enter Code: *

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