City of Victoria Form Center

2. Request for EMS Coverage
   Thank you for your interest in special even coverage from Victoria Fire Department. This form must be completed in full for consideration by Victoria Fire Department at least fifteen (15) days prior to the event. Victoria Fire Department will determine whether coverage will be offered, and if so, will determine which EMS resources will be used. If coverage is offered, you will be given confirmation along with an estimated cost.
4. Event Information:
6. Resource Type Requested: *
   -- Select One --Ambulance with CrewBike Medic Team
8. Event Date and Time: *
   Event Date and Time:

   Event Date and Time:
10. Event Name: *
12. Event Address: *
14. City*
15. State
16. Zip Code*
18. Event Type: *
20. Estimated Event Crowd Size:*
22. EMS Report Time: *
    EMS Report Time:
24. Event Start Time:
    Event Start Time:
25. Event End Time: *
    Event End Time:
27. What specific location on the property should the EMS unit be placed?*
29. Contact Person: *
    Full Name
30. Contact Email Address:*
32. Contact Phone Number: *
34. Maps of the course or venue are required and must be returned with this form unless the venue is a permanent sports or entertainment facility.
36. Map:
40. Billing Information
42. Company/ Group Name: *
44. First Name*
    Responsible Individual
45. Last Name*
47. Billing Address: *
49. City*
50. State*
51. Zip Code*
53. Phone Number*
55. Email Address*
57. Any additional information you would like to provide regarding this event:
59. Additional Information:
    Factors used to determine whether/ how coverage will be offered may include: event crowd size (1500+), risk factors for participating population, EMS access to venue (area traffic impedance), FIRE/ EMS availability and event impact on 9-1-1 operations.
    
    EMS coverage is intended for individual patient evaluation, treatment and / or transport to an emergency department. It is not intended for, and it is beyond the scope of EMS to provide "first aid station" type services, for example: pain medicine for headaches, multiple ice packs or elastic bandages, other medical supply hand-outs, bottled water, etc.
    
    Hourly fees are set by the City of Victoria. There is a 2-hour minimum, and 2 or more resources require the addition of an EMS supervisor to oversee event operations.
61. Payment for services are due one (1) business day prior to the start of the scheduled event. Payments can be made at the City of Victoria Finance Department Office (702 N. Main St).
    
    Ambulance: $95/ hr
    
    EMS Bike Team: $75/ hr
    
    EMS Supervisor: $50/ hr
Leave This Blank:


63. Submit

* indicates a required field