Ambulance Membership Program

2. Primary Member Last Name*

3. Primary Member First Name*

5. Member Date of Birth*
   Member Date of Birth

6. Member ID

   Please include your membership number if you are renewing.

7. Insurance Verification*

   1. I attest that I have medical insurance.

9. 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.

   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.

11. Type of Membership*

    1. Individual Membership - $12
    2. Family Membership - $15
    3. Senior Household Membership - $12

13. Member's Street Address*

15. City*

16. State*

17. Zip Code*

18. Phone Number*

20. Name

    N/A

21. Quantity

22. Shipping Cost

23. Taxable

25. Mailing Address (if different from street address)

27. City

28. State

29. Zip Code

31. Insurance Requirement

    Everyone enrolling in the Ambulance Membership Program MUST have medical insurance (private and/or Medicare) to qualify.

    Everyone enrolling in the Ambulance Membership Program MUST have medical insurance (private and/or Medicare) to qualify.

33. List all family members who are permanent residents of the home and will be included in the membership.

35. Spouse Last Name

36. Spouse First Name

37. Date of Birth
    Date of Birth

38. Insurance Verification

    1. Yes, this person is insured.

40. Dependent #1 Last Name

41. Dependent #1 First Name

42. Date of Birth
    Date of Birth

43. Insurance Verification

    1. Yes, this person is insured.

45. Dependent #2 Last Name

46. Dependent #2 First Name

47. Date of Birth
    Date of Birth

48. Insurance Verification

    1. Yes, this person is insured.

50. Dependent #3 Last Name

51. Dependent #3 First Name

52. Date of Birth
    Date of Birth

53. Insurance Verification

    1. Yes, this person is insured.

55. Dependent #4 Last Name

56. Dependent #4 First Name

57. Date of Birth
    Date of Birth

58. Insurance Verification

    1. Yes, this person is insured.

60. Dependent #5 Last Name

61. Dependent #5 First Name

62. Date of Birth
    Date of Birth

63. Insurance Verification

    1. Yes, this person is insured.

65. 

67. 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.
69. Electronic Signature*

70. Date of Signature*
    Date of Signature

Leave This Blank:


71. Calculate Totals Proceed to Checkout

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