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Sonoma County Paramedic Association

18th Annual Survivor's Reunion
May 19, 2011


Submission Form


REMEMBER that this form is being submitted accross the internet, and is not secure. Please do not violate any company/agency HIPPA policies, by providing any details that may identify your patient. The organizers will be able to identify your run with just the information on this form.
 
Survivors' Reunion Submission Form
 
If you were involved in an EMS related call within the past 12 months that was in some way spectacular, amazing or unique, and resulted in the saving of a life, we would like to hear about it! Each year 8 to 10 'unique' saves are featured at the Sonoma County Survivors Reunion. It is the feature event that kicks off EMS awareness week each year. Simply complete the form below to submit your call for consideration in next year's event.
 
 
Name (required):
 
Email Address (required):
 
Agency (required):
 
Phone Number (required):
 
Date of Call (required):
 
Approx. Time of Call (required):
 
Trauma or Medical? (required):
 
Receiving Facility (required):
 
Transporting Agency and Unit # (required):
 
Bystander CPR (Yes or No) (required):
 
 
 
Additional Agencies:
 
 
 
Additional Comments: