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Access Delegation Request Information

Home Access Delegation Request Information

Delegation Request Form

Contact Information

The primary contact person will be responsible for receiving the required training in advance of the event and will be responsible for the AED unit while on loan.
Primary Contact Person(Required)
Address(Required)
Secondary Contact Person(Required)

Details

Please request the dates you would like to check out and return the AED unit. Check out and returns are ONLY available Monday to Friday between 7:30 am and 4:30 pm.
Requested Check Out Date(Required)
Requested Return Date(Required)
MM slash DD slash YYYY
Event Location(Required)
Event Start Time(Required)
:
Event End Time(Required)
:
Does the venue have an AED on site?(Required)
Community, school or church, Sport or Athletic, Company, Event with guests at risk of cardiac arrest, etc.
Have you received an AED on loan from Dufferin County Paramedic Service before?(Required)

Information Collection

The information contained in this form is confidential. It contains personal health information that is subject to the provisions of the ‘Personal Health Information Protection Act, 2004’. This form and its contents should not be distributed, copied or disclosed to any unauthorized persons. If you have accessed this form in error, please contact the owner or sender immediately. All or part information from this referral form may be shared with other agencies to provide appropriate care. For questions please contact the Chief Paramedic at 519-941-9608 ext. 6001.
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