Standby Request

This form is utilized to request Standby Coverage for an event you maybe hosting within The Town of Westerly, RI and/or Pawcatuck, CT. Please fill in all requested information and a member of our staff will be in contact to discuss your event and ambulance needs. Effective July 1, 2016 there is a fee associated with this service.

Indicates Required Field

Name:
Name of Organization/Event:
Date of Event:
Start Time of Event:		00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23  : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
End Time of Event:		00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23  : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Description of Event:
Contact Information For Event Coordinator
Phone Number (xxx)xxx-xxxx:
Email Address:
Mailing Address (including city, state and zip code):
If you are in need of immediate assistance in regards to your standby request you are asked to call (401) 596-4375 X202