Dear Event Coordinator, On behalf of St. John Ambulance

							                                                                Thunder Bay and Northwestern
                                                                Ontario Administrative Office
                                                                518 Fort William Road
                                                                Thunder Bay, ON Canada P7B 2Z8
                                                                Toll Free/Sans frais: 1 (800) 667-6246
                                                                Tel./Tél.: 1 (807) 345-1712
                                                                Fax/Télécopieur: 1 (807) 343-0295
                                                                ac.ajs.www

Dear Event Coordinator,
    On behalf of St. John Ambulance I would like to say that we are looking forward to a prosperous
and productive 2009. You will find the attached 2009 Request for First Aid Coverage Form is very
similar to forms in past. We are happy to offer the services of our trained, qualified and equipped
Medical First Response Team to your events. The information that is provided on the form allows us to
be as efficient and effective as possible when it comes to preparing for your event. Please fax or drop
off a fully completed copy of the 2009 Request for First Aid Coverage Form for each and every one of
your events.
    Please keep in mind that:
         St. John Ambulance is a not-for-profit, charitable organization led primarily by volunteers.
         Since we receive no government funding we rely heavily on donations from the organizations
         we serve to help cover our costs. We incur costs for such things as training and certification,
         first aid supplies, vehicle costs, travel, administration, insurance and uniforms. We would
         greatly appreciate it if you would give consideration to this when you make your donation. You
         will be issued a charitable tax receipt.
         Often obtaining First Aid Coverage is a requirement to obtain event insurance. Also, it is
         important that a facility exists in which St John Ambulance volunteers can administer our
         services that is clean, accessible and allows for privacy, preferably with access to running
         water. This facility should be in a visible area so that participants of our event and event
         volunteers know where to go in the case of an emergency. Information relating to personal
         patient information and treatment is confidential, and cannot be disclosed to any public or
         organizing body.
         Our volunteers donate their time to the community of Thunder Bay and the region to ensure
         safety of all individuals. When providing refreshments and snacks for your event volunteers,
         please ensure that St. John Ambulance is not overlooked.
         St. John Ambulance volunteers are not permitted to administer any medication. Our volunteers
         do not carry or dispense medication of any type. Also, our volunteers are not permitted to
         transport any ill or injured person to a medical facility, either personally or in the mobile First
         Aid Post. Our Medical First Responders deal with the occurrence of injury or illness from the
         onset until the arrival of Emergency Services personnel.
         We ask that the Request for First Aid Coverage Form is completed and delivered with a
         minimum of 6 weeks notice prior to your event. If you have any questions about our needs and
         the set up of our event please feel free to contact St John Ambulance. We will contact you
         about our services at your event 2 weeks prior to the date. Events are covered on a first come
         first serve basis, and we strive to meet all requests. A donation quote can be provided at your
         request. Please indicate this on your form.

I look forward to working with you and making 2009 the best year yet.
Sincerely,



KC Woilford, Regional Community Services Coordinator
St. John Ambulance Thunder Bay & Northwestern Ontario - (807) 345-1712 ext 2
                                                                    Thunder Bay and Northwestern
                                                                    Ontario Administrative Office
                                                                    518 Fort William Road
                                                                    Thunder Bay, ON Canada P7B 2Z8
                                                                    Toll Free/Sans frais: 1 (800) 667-6246
                                                                    Tel./Tél.: 1 (807) 345-1712
                                                                    Fax/Télécopieur: 1 (807) 343-0295
                                                                    ac.ajs.www


                                   Medical First Response Unit
                             2009 Request for First Aid Coverage Form

     Please submit at least 6 weeks in advance, duties are covered on a first come, first served basis.
                           Please print and ensure that all areas are completed.
Name of Group or Organization:


Contact Person (First & Last Name):


Address:


City:                           Province:                             Postal Code:


Daytime Phone Number:                                      Evening Phone Number:


Fax Number:                                                Email:


Event Name:


Description of Event (i.e. Picnic, Concert, Sporting Event):


Contact Person at Event (First and last name & phone number):


Location of Event:


Date:                                                     Start & End Times:

Date:                                                     Start & End Times:

Date:                                                     Start & End Times

Donation Amount: (Suggested amount $50 per hour - cheques can be made payable to St. John Ambulance)


If you are unsure of the amount, a Donation Quote can be sent to you. Would you like a Donation Quote sent to
the above address?               Yes                 No
                                                                                              Page 1 of 2
Attach the following if available or applicable:
     Proposed Route Map          Tentative Site Layout        Schedule         Rain Out Plans
Are the following available on site?
     First Aid Room             Clean Drinking Water          Telephone        Parking
Do you require first aid coverage to meet your insurance/organizational requirement/policy?
     Yes                         No
Coverage is requested for (please give approximate numbers)
Age Group: ________________                 Participants: ________________
Spectators: ________________                Both: ______________________
How many Medical First Response volunteers would you like at your event? St. John Ambulance will do the best
it can to meet this request.
     As many as possible          Please limit to no more than __________

A Site Assessment can be completed for you and recommendations can be made to the number of volunteers to
have on site. Please indicate if you would like a Site Assessment.
      Yes                        No
Will food and beverages be offered at no cost to St. John Ambulance Volunteers?
     Yes                                 No

If yes, where will this food and beverage be made available?
Additional Information & Other Comments:




Signature:                                              Date:


                         For more information please call 345-1712 ext 2.


      Office Use Only:
Date Request Received:

Date Called to Confirm Receipt of Request:

Date Event Confirmed or Denied:

Signature:

Date Donation Received:

Signature:

Other Communications:




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