Ambulance Standby Service Request Form

Program Conditions, Disclaimer, and User Agreement

Please read the following conditions, disclaimer, and user agreement.

Teton County Fire & Rescue understands the importance of providing ambulance service during special events and community programs. The Ambulance Standby Services Program and the Ambulance Standby Service Request Form were created to assist in the arrangement of special ambulance coverage by Teton County Fire & Rescue Ambulance Service. Special ambulance services differ depending on the organization requesting: government, nonprofit, and commercial enterprise. The Ambulance Standby Service Request Form must be completed and returned to TCF&R at least 14 days prior to the start of the event. Payment in full is required no later than 72 hours prior to the start of the event.

The type of services offered are listed below:

Dedicated Ambulance Coverage:

This level requires the staff and equipment to remain onsite of the event until the end, without interruption. In addition, even if an organization requests and agrees to the conditions of Dedicated Standby Services, certain extreme, catastrophic, or immediate life-threatening emergencies may still require TCF&R to utilize the ambulance assigned to the Dedicated Standby. If this occurs during a scheduled Dedicated Standby (with this AGREEMENT in place), and a lapse of onsite EMS coverage occurs, another ambulance/crew will be immediately routed to the event as soon as possible.

Non-dedicated Ambulance Coverage:

This level does not require the staff or equipment to remain onsite of the event. Event coverage may be interrupted in the event of an emergency response elsewhere in the jurisdiction.

Disclaimer:

Submission of any standby request does not guarantee an ambulance standby service. The Ambulance Standby Services Program document, as well as the Ambulance Standby Service Request Form must be completed and returned to TCF&R at least 14 days prior to the start of the event. You will be contacted by Teton County Fire & Rescue to confirm we have received your standby request for service. Final confirmation of your requested service will be directly following the signed agreement and payment of the service requested. In the event that a dedicated standby crew is called away to an external immediate and emergent need, every effort will be made to restore the requested standby coverage as soon as possible.

User Agreement (required)

I have read and agree to the Ambulance Standby Service Program.

Service Level, Please select the level of service you are requesting and circle the correct fee:

Select Service, Restrictions and details will show based on selection. (required)

Organization Details, Please enter information about your organization:

Requesting Organization (required)

Organization Details: (required)

Organization Details (If Other)

Organization/Individual Mailing Address

Street Address

Address Line 2 (required)

City/State/Zip code (required)

Organization/Event Website Address: (required)

Organization Contact Email (required)

Organization Contact Person

First Name (required)

Last Name (required)

Organization Contact Person Cell Phone (required)

Event Details, Please submit your event details: (required)

Name/Title of the Event (required)

Location of the Event (required)

Date of the Event (mm/dd/yyyy) (required)

Start Time (required)

End Time (required)

If this is a multi-day event or if the event will be repeated on additional days, please describe additional details/description, or an official event schedule. (required)

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Program Conditions, Disclaimer, and User Agreement

The type of services offered are listed below:

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