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Requesting Western EMS Coverage

If you are planning an event and would like EMS coverage, please fill out the form below. Please submit as much information as you can.

Once submitted, you will be redirected to a page that confirms your submission. We will contact you to personally acknowledge receipt within 48 hours. You may email us at Western-EMS@wiu.edu with any questions.

Event Organizer Name:
Department/Organization:
Phone:
E-Mail:

Event Title:
Event Type:
Event Location:
Event Date(s):

Event Start Time:
Event End Time:

Coverage Start Time:
Coverage End Time:
Coverage times are the times that you would like EMS to be present. Please estimate what time the crowd will arrive and disperse.

Event Description:

Approximate Number of Attendees:

Do you want a staffed medical station?
If no, WEMS personnel will walk around the event. If yes, you must be able to provide a room or booth for our crew and equipment:
Location of medical station:

Has University Police been requested?
Has MDH Ambulance Service been requested? Ambulance standby is not required.

Any Additional Information you would like to provide: