EMS Summit Grant Application

Please complete the below form to apply for the Summit. Make sure to complete the entire form and then click the blue "Continue" button. Please feel free to call Michelle Fetterer at +1 847-423-5127 with any questions. We look forward to reviewing your application!

Event: 2021 EMS Summit
First Name*
Last Name*
Your Title
Pronouns*
Department*
First Name on Badge (if different from above)
E-Mail*
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Work Address*
City*
State (two-letter abbreviation)*
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Cell Phone*
Emergency Contact Person AND Phone Number*
 
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Please tell us about your organization:

What is the population size your department serves?

How many EMTs and/or Paramedics are in your department?

Is your department a transporting agency?

How many Advanced Life Support (ALS) ambulances does your department own and operate?

How many Basic Life Support (BLS) ambulances does your department own and operate?

Tell us about your department and the community it serves. (2-5 sentences)

Tell us about yourself and your role in the department. Traveler, pet owner, or cooking enthusiast? Tell us that, too! (2-4 sentences)

What is your organization currently doing well?

What are some challenges your organization is facing?

What topics would you suggest for Roundtable discussions?

What questions do you have for others in your industry?

Which EMS Chiefs or EMS Departments would you recommend we invite to the Summit? If possible, include names and organizations.

Are you responsible for the selection or recommendation of products and services for your organization?

What is your annual department budget?


What is your organization's projected need for each of the following?

New EMS Vehicles:

Communications/Dispatch Equipment:

Incident Management and Accountability Systems:

Facility Equipment and Management:

EMS Billing Services and Technology:

Apparel/Uniforms:

Airway and Respiratory Products:

Diagnostic Medical Equipment:

Please tell us about any other procurement plans over the next 6 to 18 months.

Please list 2-5 products, services, or vendors you would like to learn more about.

I Agree: If I am selected to attend the Summit, I agree to be present for all sessions, meetings, and functions while at the event.

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