Support LifeFlight Education and Patient Programs
Department Name:
State: OH PA WV County:
Municipality:
Contact: Title:
Phone Number: Cell Phone Number:
Email Address:
Requested Date and Time:
Alternate Date and Time:
Purpose of Visit:
Physical address where the event will be held:
Estimated Number Attending:
Will there be any EMS staff in attendance: Yes No (We will register the course for CMEs if "Yes")
Are you inviting any other departments: Yes No (For our information only) If yes, who:
LZ information (please include size, surface type, obstructions, landmarks, etc):
Radio Frequency: Transmit Receive PL Call Sign/Radio Contact ID:
