Organization Request Form

In order to create your organization page, enrollment form, and dashboard, we need a few details from you. Please complete the following form. We create new accounts Monday-Friday within 24-48 hours of your submission. Friday-Sunday submissions will be reviewed on Monday.

Organization Name *

Provide full name of organization

Organization Acronym

State or Province *

In what US state or Canadian province are you located?

Organization Type *

• Federal EMS department or service
• State EMS Office
• Regional Healthcare Coalition
• County Regulatory Body
• County Medical Control Authority
• Multi-Station EMS Agency
• Other

If Organization type is Other, what type of organization?

If your organization has an EMS oversight body, what is the name of it?

For example, if you are an MCA, what is your Region? If you are an agency, is your medical control authority?

Link to organization logo or homepage showing logo

Email us a 250 x 250 pixel png file logo or provide a link to it here, and we'll resize it.

Number of Sub Accounts for Parent Organization *

Parent organizations are usually the Group Leader and another administrator or a small team that would have access to each affiliated agency, agency personnel, and reports.

List the agencies or stations affiliated with your organization and the number of personnel in each *

For example, Acme Township Fire Department, 18; South Boardman Fire Department, 12.

Do you plan to purchase CAPCE subscriptions for your agencies' personnel? If so, how many seats?

A custom membership plan for your organization will be created based on the number of personnel.

Email *

Phone

We'll email or call if we have questions. Thank you!

Submit