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? *	YesNo
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: *