Ambulance Membership Program

2. PLEASE NOTE: Do Not Sign Into Account
   You do not need to create an account or sign in to your account in order to renew or sign up for the Ambulance Membership Form. Instead, just fill out the form below and proceed to checkout, which will take you to PayPal's website to complete payment.
4. Primary Member Last Name*
5. Primary Member First Name*
7. Member Date of Birth*
   Member Date of Birth
8. Member ID
   Please include your membership number if you are renewing.
9. Insurance Verification*

   1. I attest that I have medical insurance.
11. Select your Membership
    Please select which membership you would like to apply for or renew. Individual memberships are for households with one resident. A family membership covers all family members who are permanent residents of the household. Senior family memberships are available to households if the primary member is over the age of 55. You will be asked to pay online via PayPal upon completing your application. Rates have been prorated accordingly.
13. Type of Membership*

    1. Individual Membership (Under 55 years old) - $17
    2. Family Membership (Multiple members, all under 55 years old) - $23
    3. Senior Individual Membership (55 years or older) - $17
    4. Senior Family Membership (Multiple members, primary member is 55 years or older) - $19
15. Member's Street Address*
17. City*
18. State*
19. Zip Code*
20. Phone Number*
22. Name
    N/A
23. Quantity
24. Shipping Cost
25. Taxable
27. Mailing Address (if different from street address)
29. City
30. State
31. Zip Code
33. Insurance Requirement
    Everyone enrolling in the Ambulance Membership Program MUST have medical insurance (private and/or Medicare) to qualify.
35. List all family members who are permanent residents of the home and will be included in the membership.
37. Spouse Last Name
38. Spouse First Name
39. Date of Birth
    Date of Birth
40. Insurance Verification

    1. Yes, this person is insured.
42. Dependent #1 Last Name
43. Dependent #1 First Name
44. Date of Birth
    Date of Birth
45. Insurance Verification

    1. Yes, this person is insured.
47. Dependent #2 Last Name
48. Dependent #2 First Name
49. Date of Birth
    Date of Birth
50. Insurance Verification

    1. Yes, this person is insured.
52. Dependent #3 Last Name
53. Dependent #3 First Name
54. Date of Birth
    Date of Birth
55. Insurance Verification

    1. Yes, this person is insured.
57. Dependent #4 Last Name
58. Dependent #4 First Name
59. Date of Birth
    Date of Birth
60. Insurance Verification

    1. Yes, this person is insured.
62. Dependent #5 Last Name
63. Dependent #5 First Name
64. Date of Birth
    Date of Birth
65. Insurance Verification

    1. Yes, this person is insured.
67. 
69. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
71. Electronic Signature*
72. Date of Signature*
    Date of Signature
Leave This Blank:


73. Calculate Totals Proceed to Checkout

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