Membership Form

Membership Form
Please choose one option:*

I am reinstating my membership because it was used.I am renewing my membership because I have reached my expiration date.I am signing up for a new membership.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical & Mailing Address are the Same
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check this Box If You Are Gifting This Membership

Applicant Does Not Live at the Physical Address
Are you adding or removing any one from your membership?

YesNo
Names of Immediate Family Members Residing in Your Household

If you have more than 6 in your household, please use the comments section to add the additional names
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Comments or Questions?
Terms of Service*

I Agree
Information provided on this Website is not a substitute for the advice of a personal physician or other qualified healthcare professional. Always seek the advice of a physician or other qualified healthcare professional with any questions regarding medical symptoms or a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Website. If you think you or someone you are taking care of has a medical or psychiatric emergency, call 911 or go to the nearest hospital. Sierra Ambulance Service, Inc does not sell or distribute customer emails or information to third parties.

Agreement:

BY USING THIS WEBSITE AND CLICKING "I ACCEPT" ABOVE, YOU SIGNIFY YOUR AGREEMENT TO THESE TERMS, CONDITIONS, AND DETAILS REGARDING THE SIERRA AMBULANCE MEMBERSHIP. IF YOU DO NOT AGREE TO THESE TERMS AND CONDITIONS, DO NOT USE THIS WEBSITE.
Membership Terms*

I Accept the Statement Below
I agree to the membership terms and conditions and understand I must call 911 if I need an emergency ambulance. DO NOT CALL THE OFFICE IF YOU NEED AN AMBULANCE.

Upon Submission of this form, you will be redirected to our secure payment portal.
Should be Empty:

Membership Form

Names of Immediate Family Members Residing in Your Household