Mass Participation Event Medical Coverage Questionnaire

Thank you for reaching out to the Nuvance Sports Medicine Fellowship program. We offer a volunteer medical coverage service for mass sports participation events in the local Hudson Valley region. Please complete the questionnaire below and one of our participants will be in touch.

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* 1. Please provide your full name, contact information, and affiliation with event:

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* 2. Event Name:

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* 3. Event Date:

Date

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* 4. Start Time

Time

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* 5. End Time

Time

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* 6. Event Director Name and Contact Info:

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* 7. (If Applicable) Event Medical Director Name and Contact Info:

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* 8. Event Type:

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* 9. For Race Events: Indicate Distances offered.

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* 10. Anticipated Number of Participants:

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* 11. Inaugural Event?

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* 12. If No:

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* 13. Please advise of all resources to be in place (e.g. EMS | Athletic Trainer On-Site | AED | Medical Supplies etc.)

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* 14. Local EMS Resources (if known)

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