Name(Required) First Last
Preferred Method of Contact(Required) Nature of Request(Required) Please Choose Nature of Request Emotional Support Illness/Injury Line of Duty Death Religious Service Spiritual Consultation Other
Urgency of Request(Required) Please Choose Urgency Time Sensitive Routine
County (Primary Agency)(Required) Choose County Allegany Anne Arundel Baltimore County Baltimore City Calvert Caroline Carroll Cecil Charles Dorchester District of Columbia Federal Government Frederick Garrett Harford Howard Kent Montgomery Prince George's Queen Anne's Somerset St. Mary's State of Maryland State of Virginia Talbot Washington Wicomico Worcester
Select Your Primary Agency Affiliation (Allegany)(Required) Select Your Primary Agency Affiliation Allegany County Department of EMS Baltimore Pike Volunteer Fire Department, Inc. Barton Hose Company No. 1, Inc. Bedford Road Volunteer Fire Department, Inc. Bloomington Fire Company Bowling Green Volunteer Fire Department, Inc. Bowman's Addition Volunteer Fire Company, Inc. Corriganville Volunteer Fire Company, Inc. Cresaptown Volunteer Fire Department, Inc. Cumberland Fire Department (Career Dept) District 16 Volunteer Fire Department, Inc. (Cumberland) Ellerslie Volunteer Fire Company, Inc. Flintstone Volunteer Fire Company, Inc. Frostburg Area Ambulance Service Frostburg Fire Department, Inc. George's Creek Ambulance Service, Inc. Goodwill Fire Company No.1, Inc. (Lonaconing) La Vale Volunteer Fire Department, Inc. La Vale Volunteer Rescue Squad, Inc. Luke Volunteer Fire Company, Inc. Midland Volunteer Fire Department Mount Savage Volunteer Fire Company No. 1, Inc. Oldtown Volunteer Fire Department, Inc. Orleans Volunteer Fire Department, Inc. Potomac Fire Company No. 2, Inc. (Westernport) Rawlings Volunteer Fire Department, Inc. Shaft Volunteer Fire Company, Inc. Tri Towns EMS, Inc
Select Your Primary Agency Affiliation (Anne Arundel)(Required) Select Your Primary Agency Affiliation Annapolis City Fire Department Anne Arundel County Fire Department (Career Dept) Arnold Volunteer Fire Department, Inc. Arundel Volunteer Fire Department, Inc. BWI Airport Fire & Rescue Department Cape Saint Claire Volunteer Fire Company, Inc. Deale Volunteer Fire Dept & Rescue Squad, Inc. Earleigh Heights Volunteer Fire Company, Inc. Ferndale Volunteer Fire Company, Inc. Fort Meade Fire Department Glen Burnie Volunteer Fire Company, Inc. Herald Harbor Volunteer Fire Department, Inc. Jessup Volunteer Fire Department, Inc. Lake Shore Volunteer Fire Company, Inc. Maryland City Volunteer Fire Department & Rescue Squad, Inc. Odenton Volunteer Fire Company, Inc. Orchard Beach Volunteer Fire Company, Inc. Riviera Beach Volunteer Fire Company, Inc. West Annapolis Fire and Improvement Company, Inc. Woodland Beach Volunteer Fire Department, Inc.
Select Your Primary Agency Affiliation (Baltimore County)(Required) Select Your Primary Agency Affiliation Arbutus Volunteer Fire Department, Inc. Baltimore County Fire Department (Career Dept) Bowley's Quarters Volunteer Fire Department Butler Volunteer Fire Company, Inc. Chestnut Ridge Volunteer Fire Company Cockeysville Volunteer Fire Company, Inc. English Consul Volunteer Fire Department Glyndon Volunteer Fire Department Hereford Volunteer Ambulance Association Hereford Volunteer Fire Department Essex Volunteer Fire Company Jacksonville Volunteer Fire Company Kingsville Volunteer Fire Company Lansdowne Volunteer Fire Department Liberty Road Volunteer Fire Company, Inc. Long Green Volunteer Fire Company, Inc. Lutherville Volunteer Fire Company Maryland Line Volunteer Fire Company Middle River Volunteer Fire & Rescue Company North Point-Edgemere Volunteer Fire Department Owings Mills Volunteer Fire Company, Inc. Pikesville Volunteer Fire Company Providence Volunteer Fire Company, Inc. Reisterstown Volunteer Fire Company, Inc. Rosedale Volunteer Fire Company, Inc. Upperco Volunteer Fire Company White Marsh Volunteer Fire Company Wise Avenue Volunteer Fire Company, Inc. Woodlawn Volunteer Fire Company, Inc.
Select Your Primary Agency Affiliation (Baltimore City)(Required) Select Your Primary Agency Affiliation Baltimore City Fire Department
Select Your Primary Agency Affiliation (Calvert)(Required) Select Your Primary Agency Affiliation Calvert County Advanced Life Support, Inc. (Mobile ICU) Calvert County Fire-Rescue-EMS Division Dunkirk Volunteer Fire Department & Rescue Squad Huntingtown Volunteer Fire Department & Rescue Squad, Inc. North Beach Volunteer Fire Department, Inc. Prince Frederick Volunteer Fire Department, Inc. Prince Frederick Volunteer Rescue Squad, Inc. Solomons Volunteer Rescue Squad and Fire Department, Inc. St Leonard Volunteer Fire Department & Rescue Squad, Inc.
Select Your Primary Agency Affiliation (Caroline)(Required) Select Your Primary Agency Affiliation Caroline County Emergency Medical Services Denton Volunteer Fire Company, Inc. Federalsburg Volunteer Fire Company, Inc. Goldsboro Volunteer Fire Company, Inc. Greensboro Volunteer Fire Company Marydel Volunteer Fire Company, Inc. Preston Volunteer Fire Company, Inc. Ridgely Volunteer Fire Department, Inc.
Select Your Primary Agency Affiliation (Carroll)(Required) Select Your Primary Agency Affiliation Carroll County Emergency Services Gamber and Community Fire Company Hampstead Volunteer Fire Engine & Hose Company No. 1 Harney Volunteer Fire Company Lineboro Volunteer Fire Department, Inc. Manchester Volunteer Fire Department and Hook & Ladder Co. No. 1 Mount Airy Volunteer Fire Company, Inc. New Windsor Fire & Hose Company No. 1 Pleasant Valley Community Fire Company, Inc. Reese & Community Volunteer Fire Company, Inc. Sykesville-Freedom District Fire Department, Inc. Taneytown Volunteer Fire Company Union Bridge Fire Company, Inc. Westminster Fire Engine & Hose Company No. 1 Winfield Community Volunteer Fire Department, Inc.
Select Your Primary Agency Affiliation (Cecil)(Required) Select Your Primary Agency Affiliation Cecil County Department of Emergency Services Cecilton Volunteer Fire Company, Inc. Charlestown Fire Company, Inc. Community Fire Company of Perryville, Inc. Community Fire Company of Rising Sun, Inc. Hacks Point Fire Company, Inc. North East Fire Company, Inc. Wm. M. Singerly Steam Fire Engine & Hook & Ladder Company No.1 (Elkton) Water Witch Fire Company, Inc. Volunteer Fire Company No. 1 of Chesapeake City, Inc.
Select Your Primary Agency Affiliation (Charles)(Required) Select Your Primary Agency Affiliation Bel Alton Volunteer Fire Department, Inc. Benedict Volunteer Fire Department & Rescue Squad, Inc. Bryans Road Volunteer Fire Department & Rescue Squad, Inc. Charles County Emergency Medical Services Charles County Volunteer Rescue Squad Cobb Island Volunteer Fire Department & EMS, Inc. Dentsville Volunteer EMS & Auxiliary Inc. Hughesville Volunteer Fire Dept. & EMS, Inc. Indian Head Volunteer Fire Department, Inc. Ironsides Volunteer Rescue Squad La Plata Volunteer Fire Department, Inc. Nanjemoy Volunteer Fire Department Newburg Volunteer Rescue Squad and Fire Department Potomac Heights Volunteer Fire Department & Rescue Squad, Inc. Tenth District Volunteer Fire Department, Inc. (Marbury) Waldorf Volunteer Fire Department, Inc.
Select Your Primary Agency Affiliation (Dorchester)(Required) Select Your Primary Agency Affiliation Church Creek Volunteer Fire Company, Inc. Dorchester County Emergency Medical Services East New Market Volunteer Fire Company, Inc. Eldorado-Brookview Volunteer Fire Company Elliott Island Volunteer Fire Company Hooper's Island Volunteer Fire Company Hurlock Volunteer Fire Company Lakes & Straits Volunteer Fire Company, Inc. Linkwood-Salem Volunteer Fire Company Madison Volunteer Fire Company, Inc. Neck District Volunteer Fire Company, Inc. Rescue Fire Company, Inc. (Cambridge) Secretary Volunteer Fire Company, Inc. Taylors Island Volunteer Fire Company, Inc. Vienna Volunteer Fire Company, Inc.
Select Your Primary Agency Affiliation (District of Columbia)(Required) Select Your Primary Agency Affiliation District of Columbia
Select Your Primary Agency Affiliation (Federal Government)(Required) Select Your Primary Agency Affiliation Aberdeen Proving Ground Fort Meade Fort Detrick/Forest Glen Naval District Washington Fire & Emergency Department NIH NIST
Select Your Primary Agency Affiliation (Frederick)(Required) Select Your Primary Agency Affiliation Braddock Heights Volunteer Fire Company, Inc. Brunswick Volunteer Ambulance Company Brunswick Volunteer Fire Company Carroll Manor Fire Company, Inc. (Adamstown) Citizens Truck Company No. 4 (Frederick) Emmitsburg Community Ambulance Fort Detrick Fire Department Frederick County Division of Fire and Rescue Services (Career) Graceham Volunteer Fire Company, Inc. Guardian Hose Company, Inc. (Thurmont) Independent Hose Company No. 1 (Frederick) Jefferson Volunteer Fire Company, Inc. Junior Fire Company No. 2 Lewistown District Volunteer Fire Dept, Inc. Libertytown Volunteer Fire Department, Inc. Middletown Volunteer Fire Company, Inc. Myersville Volunteer Fire & Rescue Company, Inc. New Market District Volunteer Fire Department New Midway Volunteer Fire Company, Inc. Rocky Ridge Volunteer Fire Company, Inc. Thurmont Community Ambulance Service United Steam Fire Engine Company No. 3 Urbana Volunteer Fire Department, Inc. Vigilant Hose Company, Inc. (Emmitsburg) Walkersville Volunteer Fire Company, Inc. Walkersville Volunteer Rescue Company, Inc. Wolfsville Volunteer Fire Company, Inc. Woodsboro Volunteer Fire Company, Inc.
Select Your Primary Agency Affiliation (Garrett)(Required) Select Your Primary Agency Affiliation Accident Volunteer Fire Department, Inc. Bittinger Volunteer Fire Department, Inc. Deep Creek Volunteer Fire Company, Inc. Deer Park Volunteer Fire Department, Inc. Eastern Garrett County Volunteer Fire Company Friendsville Volunteeer Fire and Rescue Department, Inc. Garrett County Department of Public Safety Gorman Volunteer Fire Department, Inc. Grantsville Volunteer Fire Department, Inc. Kitzmiller Volunteer Fire Department Northern Garrett County Rescue Squad Oakland Volunteer Fire Department, Inc. Southern Garrett County Rescue Squad
Select Your Primary Agency Affiliation (Harford)(Required) Select Your Primary Agency Affiliation Aberdeen Fire Department, Inc. Aberdeen Proving Ground Fire & Emergency Services Abingdon Fire Company, Inc. Bel Air Volunteer Fire Company, Inc. Darlington Volunteer Fire Company, Inc. Fallston Volunteer Fire & Ambulance Company, Inc. Harford County Volunteer Fire and EMS Foundation Havre De Grace Ambulance Corps. Inc. Jarrettsville Volunteer Fire Company, Inc. Joppa-Magnolia Volunteer Fire Company, Inc. Level Volunteer Fire Company, Inc. Norrisville Volunteer Fire Company Susquehanna Hose Company, Inc. (Havre De Grace) Whiteford Fire Department
Select Your Primary Agency Affiliation (Howard)(Required) Select Your Primary Agency Affiliation Elkridge Volunteer Fire Department, Inc. Ellicott City Volunteer Firemen's Association Fifth District Volunteer Fire Department, Inc. (Clarksville) Howard County Department of Fire And Rescue (Career) Lisbon Volunteer Fire Company, Inc. Savage Volunteer Fire Company, Inc. West Friendship Volunteer Firemen's Association, Inc.
Select Your Primary Agency Affiliation (Kent)(Required) Select Your Primary Agency Affiliation Betterton Volunteer Fire Company, Inc. Chestertown Volunteer Fire Company, Inc. Community Fire Company, Inc. of Millington Galena Volunteer Fire Company, Inc. Kennedyville Volunteer Fire Company, Inc. Rock Hall Volunteer Fire Company, Inc.
Select Your Primary Agency Affiliation (Montgomery)(Required) Select Your Primary Agency Affiliation Bethesda Fire Department, Inc. Bethesda-Chevy Chase Rescue Squad, Inc. Burtonsville Volunteer Fire Department, Inc. Cabin John Volunteer Fire Department Damascus Volunteer Fire Department, Inc. Gaithersburg-Washington Grove Fire Dept., Inc. Germantown Volunteer Fire Department Inc. Glen Echo Fire Department Hillandale Volunteer Fire Department, Inc. Hyattstown Volunteer Fire Department, Inc. Kensington Volunteer Fire Department, Inc. Laytonsville District Volunteer Fire Department, Inc. Montgomery County Fire & Rescue Service (Career) Rockville Volunteer Fire Department, Inc. Sandy Spring Volunteer Fire Department, Inc. Silver Spring Volunteer Fire Department, Inc. Takoma Park Volunteer Fire Department, Inc. Upper Montgomery County Volunteer Fire Department, Inc. Wheaton Volunteer Rescue Squad, Inc.
Select Your Primary Agency Affiliation (Prince George's)(Required) Select Your Primary Agency Affiliation Accokeek Volunteer Fire Department, Inc. Allentown Road Volunteer Fire Department, Inc. Baden Volunteer Fire Department, Inc. Beltsville Volunteer Fire Department, Inc. Berwyn Heights Volunteer Fire Dept. & Rescue Squad, Inc. Bladensburg Volunteer Fire Department & Rescue Squad, Inc. Boulevard Heights Volunteer Fire & Rescue Department, Inc. Bowie Volunteer Fire Department & Rescue Squad, Inc. Branchville Volunteer Fire Company & Rescue Squad, Inc. Brandywine Volunteer Fire Department & Rescue Squad Brentwood Volunteer Fire Department, Inc. Bunker Hill Volunteer Fire & Rescue Co., Inc. (Co 55) Capitol Heights Volunteer Fire Department Chapel Oaks Volunteer Fire Department Sta. 38 Chillum-Adelphi Volunteer Fire Department, Inc. Sta. 34 Clinton Volunteer Fire Department, Inc. College Park Volunteer Fire Department, Inc. District Heights Volunteer Fire Department, Inc. Forestville Volunteer Fire Department, Inc. Glenn Dale Fire Association, Inc. Greenbelt Volunteer Fire Department & Rescue Squad, Inc. Hyattsville Volunteer Fire Department, Inc. Kentland Volunteer Fire Department & Rescue Squad Landover Hills Volunteer Fire Department, Inc. Laurel Volunteer Fire Department, Inc. Laurel Volunteer Rescue Squad, Inc. Marlboro Volunteer Fire Department, Inc. Morningside Volunteer Fire Department, Inc. Oxon Hill Volunteer Fire Department & Rescue Squad Prince George's County Fire & EMS Department (Career) Prince George’s County Volunteer Marine Fire-Rescue Ritchie Volunteer Fire Department Riverdale Fire Department, Inc. Riverdale Heights Volunteer Fire Department, Inc. Seat Pleasant Volunteer Fire Company, Inc. Silver Hill Volunteer Fire Department & Rescue Squad, Inc. West Lanham Hills Volunteer Fire Department
Select Your Primary Agency Affiliation (Queen Anne's)(Required) Select Your Primary Agency Affiliation Church Hill Volunteer Fire Company, Inc. Crumpton Volunteer Fire Department Goodwill Volunteer Fire Company, Inc. (Centreville) Grasonville Volunteer Fire Department, Inc. Kent Island Volunteer Fire Department, Inc. Kent-Queen Anne's Rescue Squad Queen Anne's County Department of Emergency Services Queenstown Volunteer Fire Company, Inc. Sudlersville Volunteer Fire Department, Inc. United Communities Volunteer Fire Department
Select Your Primary Agency Affiliation (Somerset)(Required) Select Your Primary Agency Affiliation Crisfield Volunteer Fire Department Deal Island-Chance Volunteer Fire Company, Inc. Ewell Volunteer Fire Company, Inc. Fairmount Volunteer Fire Company Lower Somerset County Ambulance & Rescue Squad Inc Marion Volunteer Fire Department Mount Vernon Volunteer Fire Company Princess Anne Volunteer Fire Company, Inc. Tylerton Volunteer Fire Company
Select Your Primary Agency Affiliation (St. Mary's)(Required) Select Your Primary Agency Affiliation Bay District Volunteer Fire Department, Inc. (Station 3) Hollywood Volunteer Fire Department, Inc. Hollywood Volunteer Rescue Squad Leonardtown Volunteer Fire Department, Inc. Leonardtown Volunteer Rescue Squad Lexington Park Volunteer Rescue Squad Mechanicsville Volunteer Fire Department, Inc. Mechanicsville Volunteer Rescue Squad Ridge Volunteer Fire Department, Inc. Ridge Volunteer Rescue Squad Second District Volunteer Fire Department & Rescue Squad (Valley Lee) Seventh District Volunteer Fire Department, Inc. (Avenue) Seventh District Volunteer Rescue Squad St Mary's Advanced Life Support
Select Your Primary Agency Affiliation (State of Maryland)(Required) Select Your Primary Agency Affiliation Maryland Dept. of the Environment Maryland Dept. of Emergency Management Maryland State Fire Marshal's Office
Select Your Primary Agency Affiliation (Talbot)(Required) Select Your Primary Agency Affiliation Cordova Volunteer Firemen's Association, Inc. Easton Volunteer Fire Department, Inc. Oxford Fire Company, Inc. Queen Anne-Hillsboro Volunteer Fire Company Saint Michael's Volunteer Fire Department Talbot County Advanced Life Support Tilghman Volunteer Fire Department Trappe Volunteer Fire Company
Select Your Primary Agency Affiliation (Washington)(Required) Select Your Primary Agency Affiliation Antietam Fire Company, Inc. No. 2 (Hagerstown) Boonsboro Ambulance and Rescue Service, Inc. Clear Spring Ambulance Club Clear Spring Volunteer Fire Company, Inc. Community Rescue Service, Inc. (Hagerstown) Community Volunteer Fire Company District 12, Inc. (Fairplay) First Hagerstown Hose Company First Hose & Rescue Company of Boonsboro, Inc. Funkstown Volunteer Fire Company Hagerstown Fire Department Halfway Volunteer Fire Company Hancock Rescue Squad Hancock Volunteer Fire Company, Inc. Independent Junior Fire Company No. 3 (Hagerstown) Leitersburg Volunteer Fire Company, Inc. Longmeadow Volunteer Fire Company, Inc. Maugansville Goodwill Volunteer Fire Company Mount Aetna Volunteer Fire Department, Inc. Pioneer Hook & Ladder Company No. 1 (Hagerstown) Potomac Valley Fire Company Sharpsburg Rescue Squad Sharpsburg Volunteer Fire Company Smithsburg Community Volunteer Fire Department Smithsburg Emergency Medical Services South Hagerstown Fire Company No.5 Washington County Division of Emergency Services Washington County Special Operations Washington County Volunteer Fire Rescue Association Western Enterprise Fire Engine Company, Inc. No. 4 Williamsport Volunteer Fire and EMS Company, Inc.
Select Your Primary Agency Affiliation (Wicomico)(Required) Select Your Primary Agency Affiliation Allen Volunteer Fire Company, Inc. Delmar Fire Department, Inc. Fruitland Volunteer Fire Company Hebron Volunteer Fire Department, Inc. Mardela Springs Volunteer Fire Company, Inc. Parsonsburg Volunteer Fire Company, Inc. Pittsville Volunteer Fire Department Powellville Volunteer Fire Company, Inc. Salisbury Fire Department Company No. 1 Salisbury Fire Department, Inc. (Headquarters) Sharptown Fire Department, Inc. West Side Volunteer Fire Department (Bivalve) Willards Volunteer Fire Company
Select Your Primary Agency Affiliation (Worcester)(Required) Select Your Primary Agency Affiliation Bishopville Volunteer Fire Department, Inc. Girdletree Volunteer Fire Company, Inc. Newark Volunteer Fire Company, Inc. Ocean City Fire Department Ocean Pines Volunteer Fire Department, Inc. Pocomoke City EMS Pocomoke City Volunteer Fire Company Showell Volunteer Fire Department, Inc. Snow Hill Volunteer Fire Company, Inc. Stockton Volunteer Fire Company, Inc.