Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Ambulance Membership Program

  1. 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.

  2. Please include your membership number if you are renewing.

  3. Insurance Verification*

  4. 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.

  5. Type of Membership*

  6. Insurance Requirement

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

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

  8. Insurance Verification

  9. Insurance Verification

  10. Insurance Verification

  11. Insurance Verification

  12. Insurance Verification

  13. Insurance Verification

  14. AMP Agreement

  15. 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.

  16. Leave This Blank: