Special Event Request

2069 Battersea Road Glenburnie, ON. K0H 1S0

Phone: 613 548-9400

Event Name(Required)

Venue Name(Required)

Venue Address(Required)

Street Address State / Province / Region ZIP / Postal Code

Event Date(Required)

Event Start Time(Required)

Event End Time(Required)

Approximate number of attendees(Required)

Approximate age range of attendees(Required)

Do you have an existing contract with the County of Frontenac/Frontenac Paramedics(Required)

Yes

Time Paramedics are required on site(Required)

Time Paramedics can leave(Required)

Will Paramedics be dedicated to one group (only required to respond to event staff, performers, ect.)?(Required)

Number of paramedics required.(Required)

Name of person organizing Paramedic Coverage(Required)

Contact Phone Number(Required)

Contact Email(Required)

Organization or Person to be Billed(Required)

Billing Address

Billing Email(Required)

On-site contact name for date of event(Required)

First Last

On-Site contact phone number

Where will the ambulance be able to park?

General Comments

Would you like a copy emailed to you?

Yes