ECMRC Request Form

Thank you for your interest in the Erie County Medical Reserve Corps (ECMRC). Please complete and submit this form to request our presence at your event.

If you have any questions, please contact us at (716) 858-7101 or ECMRC@erie.gov.

If you prefer, you can complete and mail this printable application.

First

Last

Organization

Address

City/Town

State

ZIP Code

Phone number

Confirm email

Date ECMRC requested

Time ECMRC requested

Location of event

Description of event

Purpose of event

Responder Awareness

Community Service

Requesting

Information and demonstration of services

First Aid support

Specify the First Aid support