Section A As the Northern Territory’s leading provider in emergency medical response and preparedness, St John NT provides critical support in the planning and implementation of events across the Territory. No matter the size, we are able to assess the situation, and determine the most appropriate level of clinical coverage.Section A: Acknowledgement St John NT is committed to providing a quality Event Health Service to our community, as such we require a minimum of 6 weeks’ notice for coverage consideration. Prior to completing your request for coverage please indicate that you have read and understood the following conditions, please tick: I acknowledge that the quote provided by St John NT is based on the provision that the information provided by the event organiser is correct and a true delineation of the event nature. I understand the St John NT cannot guarantee that a booking received less than 30 business days prior to an event will be resourced. I understand the St John NT is volunteer based and as such coverage cannot be guaranteed. I understand that it is the responsibility of the event organiser to declare any significant changes to the event to St John NT immediately. I understand that should details change, there may be a change in cost associated and a new quote provided, and that St John NT cannot guarantee the supply of any additional resources that may be required. I understand that St John NT will provide a quote based on industry expertise and internal assessments that may recommend a level of resourcing that differs from the event organisers nominated and/or preferred level of coverage. I understand that should a situation occur which exhausts our normal resources external to the event that St John NT reserves the right to terminate your booking or withdraw resources from your fixture until the emergency has been attended to, with an appropriate reduction in charges applying. Organisation Contact Name Date signature Sign above Section B: Organisation Details Organisation Name Contact Name Position Postal Address Business Phone Mobile Email Address ABN Invoicing details Does your organization have First Aiders with current accreditation? Yes No Will they be onsite for the duration of the event? Yes No If so, how many? Section C: Event Details Event Name Event Coordinator Coordinator Phone Event Address Event Date(s) Event Start Time Event End Time Times you require St John NT On Duty Times you require St John NT Off Duty Event Type (Concert, Festival, Rodeo, Etc.) Description of Event (Include event history, anticipated number of participants & spectators, atmosphere, activities at event) Event Setting Indoor Outdoor Both Alcohol Availability BYO Permitted Licensed & Limited Licensed & Unlimited Uncontrolled N/A Event Category - None - Commercial Not-For-Profit Other Is food available on site? (If the event is longer than 4 hours or at mealtimes) Yes No Is complimentary food or vouchers available for our volunteers? Yes No Please specify (e.g. lunch, tea/coffee) Please select the available options from the list below during the event or on-site First Aid Room Shaded area Telephone Reception Security Accommodation Police Service Vehicle Access Vehicle Parking Clean drinking water Table & chairs Power outlet or supply Amenities (Toilets) Is Public Liability insurance in place for this event? - None - Yes No If Yes, Insurer Policy number Does your insurance specify the minimum level of First Aid coverage? Yes No If yes, what is required? Does your event or insurance require St John NT’s attendance to continue? Yes No Please supply a copy of your Insurance Policy, Certificate of Currency and copies of Internal Risk Assessments conducted We request that the following information be attached (if available/applicable): Proposed route map Tentative site layout Schedule/Program Wet weather plans List of contact numbers (Event Coordinator, Security, other) Unlimited number of files can be uploaded to this field.5 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Please list any special equipment you require Please provide any additional information you believe will assist us
