Required fields are marked with asterisks (*)

Medical Coverage Request Form

*Due to high operational demands and the current strains within the health care system, available medical coverage for these events is limited. These will be looked at on a case by case basis. Delays in responding may occur.*

Essex-Windsor Emergency Medical Services provides dedicated paramedic medical coverage for special events. Coverage is often dependent on the availability of staff and ambulances.

Fees apply.

Please provide at least 4 weeks advance notice for your event.

If you would like to request medical coverage for your special event, please fill out this form and an Essex-Windsor EMS representative will contact you.

Please note, if you would like to request a paramedic presentation at your school, business or other location, please use our "Paramedic Public Relations Request" form.

Name (person submitting this request):

Email (person submitting this request):

Event Information

Have we covered this event before?

Yes

Date of Event:

Medical Coverage Start Time:

Medical Coverage End Time:

Name of Event:

Location of Event:

Event Description:

On scene contact name:

On scene contact number:

Reporting location:

Ambulance Area (if applicable):

Medical Coverage Type

Please select the type of coverage that you will require for your event.

4 HOUR MINIMUM applies to all coverage (mandatory hour required for pre and post preparation and travel - included in the 4 hour minimum).

Type of medical coverage required:

1 Ambulance, 2 Paramedics

1 Emergency Response Vehicle with 1 Paramedic

1 Bike Patrol Unit (Paramedic Fee Not Included - See Bylaw)

Additional Paramedic* (without vehicle - private coverage)

Supervisor Coverage (1 Emergency Response Vehicle, 1 Supervisor)

ATV - KORA/Gator (Includes trailer and tow vehicle pickup and delivery)

Trailer Response (must have min. 2 medics on site - not included in fee)

*Additional Paramedic - please note - due to transportation to the event and the weight and volume of the medical supplies they must carry, paramedics are not able to provide coverage at an event unless a vehicle is present (ambulance, ERV, bike, ATV or trailer).

Fees charged for the above requests are in accordance with By-law #2020-13

Billing Information

This information will be used for preparation of your quote and service agreement. You will not be billed until a quote and service agreement have been approved and signed.

Event Organizer Name (Company Name):

Event Organizer Address (Billing Address):

Contact Name:

Contact Phone Number:

Extension (if applicable):

Contact Email:

Comments:

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Medical Coverage Request Form

Event Information

Medical Coverage Type

Billing Information