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Paramedic Services Community Outreach Form

Please provide us with contact information we can use to follow up with this request.

Organization Name:

Contact Name:

E-mail Address:

Phone Number:

Fax Number:

Address:

City:

Postal Code:

How should we contact you?

E-mail

Fax

Mail

Phone

Please provide the information about your event's location, as well as a way to reach you on-site of the event.

Event Title:

Event Address:

Event City:

Event Postal Code:

On-Site Contact:

On-Site Contact #:

Date of the Event:

Time of the Event:

Expected Duration: (in hours)

Estimate # of Attendees:

Please describe your event's topic of interest, what it's called, and how you would like Perth County Paramedic Services to help. The more description provided the easier it will be for us to help: