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Ambulance Membership Program
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
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.
Primary Member Last Name
*
Primary Member First Name
*
Member Date of Birth
*
Member Date of Birth
Member ID
Please include your membership number if you are renewing.
Insurance Verification
*
I attest that I have medical insurance.
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.
Type of Membership
*
Individual Membership (Under 55 years old) - $27
Senior Individual Membership (55 years or older) - $27
Family Membership (Multiple members, all under 55 years old) - $37
Senior Family Membership (2+ members of the household 55 years or older) - $30
Member's Street Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Name
N/A
Quantity
Shipping Cost
Taxable
Mailing Address (if different from street address)
City
State
Zip Code
Insurance Requirement
Everyone enrolling in the Ambulance Membership Program MUST have medical insurance (private and/or Medicare) to qualify.
List all family members who are permanent residents of the home and will be included in the membership.
Spouse Last Name
Spouse First Name
Date of Birth
Date of Birth
Insurance Verification
Yes, this person is insured.
Dependent #1 Last Name
Dependent #1 First Name
Date of Birth
Date of Birth
Insurance Verification
Yes, this person is insured.
Dependent #2 Last Name
Dependent #2 First Name
Date of Birth
Date of Birth
Insurance Verification
Yes, this person is insured.
Dependent #3 Last Name
Dependent #3 First Name
Date of Birth
Date of Birth
Insurance Verification
Yes, this person is insured.
Dependent #4 Last Name
Dependent #4 First Name
Date of Birth
Date of Birth
Insurance Verification
Yes, this person is insured.
Dependent #5 Last Name
Dependent #5 First Name
Date of Birth
Date of Birth
Insurance Verification
Yes, this person is insured.
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.
I agree.
Electronic Signature
*
Date of Signature
*
Date of Signature
Leave This Blank:
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Proceed to Checkout
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