Special Event Request

Which ambulance service would you like to request? *

Tri-State Ambulance (La Crosse / Viroqua)
Tri-State Regional Ambulance (Prairie du Chein and West Union)

Name of Company or Organization *

First and Last Name of Requestor *

Company or Organization Type *

Non-profit / Charity
Community-based
School / Educational
For-profit

Contact Email *

Contact Phone *

Type of Service Requested *

Dedicated Ambulance – Ambulance solely dedicated to your event. Must be requested at least 2 weeks in advance. An hourly fee may apply.
Non-Dedicated Ambulance – A non-dedicated ambulance may be dispatched to your event based upon availability.
Bike Team – An hourly fee may apply.
Paramedic or EMT for a speaking or educational event

Event Title *

Event Location/Address *

Projected Attendance *

Start Date / Time of Event *

Date

Time

End Date / Time of Event *

Date

Time

Additional Information (Please include any additional specific information you feel may be necessary for us to successfully staff your event. If the event is multiple days with different start/stop times, please note that here. There is no need to submit separate event requests for each day.)

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Email *

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