Carolinas HealthCare System

Thank you for your interest in the medical coverage services at Carolinas Medical Center.

You will be contacted via email and/or phone number listed in your request with 7 days. Filing a request does not imply guaranteed medical coverage.

Please contact the Carolinas Medical Center’s Department of Sports Medicine & Special Events at 704-512-3820 if you have any immediate questions.

* Indicates required information
Today's Date: * 
Billing Information 
Organization: * 
Contact Name: * 
Address: * 
City: * 
State: * 
Zip: * 
Office Number: * 
E-mail * 
Event Information 
Name of Event * 
Date(s) of Event: * 
Start time of Event: * 
Finish Time (approx.) of Event: * 
Venue Name: * 
Venue Address: * 
Venue City: * 
Venue State: * 
Venue Zip: * 
Expected attendance:  * 
Age Range of Attendance: * 
Expected athlete attendance: * 
Age Range of Athletes: * 
Name of Contact at the event: * 
Cellular Number: * 
Medical Coverage Request 
Staff certification level requested and number personnel requested:  
Physician (MD): * 

If yes, # personnel requested: 
Paramedic: * 

If yes, # personnel requested: 
Emergency Medical Technician (EMT): * 

If yes, # personnel requested: 
Registered Nurse (RN): * 

If yes, # personnel requested: 
Athletic Trainer (ATC): * 

If yes, # personnel requested: 
Request an ambulance(s) for venue site(s): (*Required staffing of one Paramedic and one EMT*) * 

Request for Mobile Sports Medicine vehicle (non-transport): (*Minimum of 2 staff*) * 

Comments/ Questions: 
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