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Peel Regional Paramedic Services Community Outreach Form

Due to the number of invalid submissions we receive, we now require you to validate your form by typing out the partly obscured numbers represented in the image below:

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Organization Name:
Organization Type:

Please provide us with contact information we can use to
follow up with this request.
* Contact Name:
* Phone Number:
Alternate Phone Number:
Fax Number:
E-mail Address:
Address:
 
City:
Postal Code:

How should we contact you?
E-mail    Fax    Mail    Phone


Please provide the information about your event's location, as well as a way to reach you on-site of the event.

* Event Title:
* Event Type:
* Event Address:
 
* City:
* Nearest Intersection:
Postal Code:
* On-Site Contact #:
Alternate Phone Number:
Fax Number:
E-mail Address:

* Date and Time
of the Event:

/ /
( mm / dd / yyyy )
  :

* Expected Duration:
(in hours)
* Estimate # of Attendees:
* Attendee Age Group :

* Please describe your event's topic of interest, what it's called, and how you would like Peel Emergency Services to help. The more description provided the easier it will be for us to help:

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