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American Family Children's Hospital
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Med Flight Fire and EMS Request Form

UW Health's Med Flight program is proud to be partners in emergency critical care and transport with fire and EMS programs and surrounding hospitals in Wisconsin, Illinois, Iowa, Michigan and Minnesota.

 

Med Flight staff provides training in setting up and securing a landing zone, preparing patients for transport, review of specific cases or types of patients, or topics of interest to your program.

 

If you are requesting on behalf of a Fire Service or EMS Program, complete this form. UW Med Flight staff will follow up within two weeks to confirm whether we can accommodate your request. At that point, we may need to gather additional information.

 
 
Date and Time Requested
 
Name of Fire Service or EMS Program
 
Requesting the following:
 
Landing Zone Education
EMS Education (add details below)
Attend Event (add details below)
 
Topics for EMS Education and/or Name of Event
 
Would you like the helicopter to attend?
 
Yes
No
 
Address of Landing Zone (please list any cross roads)
 
Agency Securing Landing Zone
 
 
CONTACT INFORMATION
 
Name
 
Phone Number
 
 
 
DAY OF CONTACT INFORMATION (if different from above)
 
Name
 
Phone Number
 
 
Details/Other Information
 
 
OFFICE USE ONLY
 
Follow Up
 
Date Verified
 
 
By
 
Map and Coordinates Printed
 
 
Added to the Calendar