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2. 

4. STANDBY REQUEST MUST BE SUBMITTED ONE WEEK PRIOR TO EVENT FOR SCHEDULING.

6. Identity of Requestor of Service

   The requestor of service (hereafter requestor) is identified as follows.

8. First Name*
9. Last Name*
11. Address
13. City
14. State
15. Zip Code
17. Phone Number*
18. Fax Number
20. Email Address*
22. Type of Entity:*

    1. Beaufort County Government
    2. Beaufort County Schools
    3. Beaufort County Community College
    4. Charter/Private School
    5. Other
24. If Other, please descibe:
26. Service Requested

    Requestor requires one emergency medical services (EMS) unit available to provide pre-hospital emergency medical care in accordance with County EMS policies/procedures at the following location.

28. Event Name:*
30. Event Address*
32. City*
33. State*
34. Zip Code*
36. From:*
    From:

    From:
37. To:*
    To:

    To:
39. The requestor understands that this truck is not dedicated to this event, this is due to utilizing an Emergency Ambulance for this standby. If a 911 call comes in and this truck is dispatched, they will have to leave the event.*

    1. Yes
    2. No
43. Equipment, Tools, Materials, and/or Supplies

    County EMS shall supply an EMS unit with the necessary equipment, tools, materials, and/or supplies as outlined by the North Carolina Office of Emergency Medical Services (NCOEMS) to accomplish the job agreed to be performed unless otherwise notified.  The Requestor agrees to provide a means of shelter from the environment sufficient enough to perform the requested service and sanitation provisions for the EMS personnel as reasonably required by circumstances. 

45. Waiver of Admissions and Entry Fee

    EMS personnel providing the requested service shall not be charged for admission or entry to the event for which they have been requested. 

47. Workers compensation and Liability Insurance

    County provides workers compensation and liability insurance for its employees that render services in the course of their duty with County and in accordance with County policies and procedures. 

49. Term of Agreement

    This agreement shall begin upon approval of this document and shall terminate at the conclusion of the requested service preformed, provided however that the terms of this agreement shall be deemed to Page 2 of 4 WC Ambulance Request  apply and control during any subsequently requested services for which an updated agreement is not otherwise executed between the parties unless and until Requestor notifies Beaufort County otherwise in writing.  

51. Termination with Reasonable Cause

    With reasonable cause, either party may terminate this agreement effective immediately upon giving written notice of termination for reasonable cause.  Reasonable cause shall include: 

    A. A material violation of this agreement by the other party 

    B. Any act committed by the non-terminating party exposing the terminating party to liability for personal injury or property damage. 

    C. Cancellation by either party for any reason with at least ten (10) days prior notice. 

    D. Cancellation of the event for which the service was requested beyond Requestor’s reasonable control, with at least seventy two (72) hours prior notice. 

53. Release of Liability

    Requestor agrees to hold and save completely harmless, and to fully indemnify County (including any and all officials, officers, employees, and/or agents thereof) from any and all litigation, and against any and all actions, liability, claims, suits, damages, cost or other expenses of any kind whatsoever (including without limitation attorneys’ fees incurred for actual or threatened litigation) which may be brought or made against, or which may otherwise be incurred by County (including any and all officials, officers, employees, and/or agents thereof), or which may otherwise accrue and result to any other person, firm, or corporation furnishing or supplying any work, services, materials, or supplies in connection with any person, firm, or corporation that may be injured or damaged (including both personal and property damages) from the negligent or tortious action(s) or inaction(s) of Requestor (including any and all subcontractors or the respective officers, employees, and/or agents of either and/or all of them), or which County must otherwise pay and/or incur by reason of, or in any manner resulting from, any injury, loss or damage to persons or property resulting from any negligent or tortious action(s) or inaction(s) of Requestor (or of any and all subcontractors or the respective officers, employees, and agents of either and/or all of them), in the performance of this agreement. 

55. REQUESTOR NAME:
56. TITLE:
58. Date & Time:
    Date & Time:

    Date & Time:
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field