2024-2025 Ambulance Membership Application
AVFD only -or- AVFD + AirMedCare
Contact Information
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Full Name
*
First Name
Last Name
Street Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Check if
New Member
New Address
Primary Member Name (if different than above)
First Name
Last Name
Primary Member Mailing Address (if different than above)
Street Address
Street Address Line 2
City
State
Zip Code
Primary Member Birthday
*
-
Month
-
Day
Year
Date
Additional Family Members
These include the primary member's spouse or partner, other immediate family members living at the same residence, and dependent children away at school. Memberships are for named persons only and are not transferable. Please contact us with questions or concerns about these definitions.
List additional family members in the household here:
Ambulance and AirMedCare Membership Enrollment
A completed Agreement is required for any option. Please take time to read and fill out completely; an incomplete application may delay your coverage. Prices shown below are for annual membership for you and your Other Family Members listed above. Please check one or more boxes.
Select your membership
*
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AVFD + AirMedCare
Combination Membership July 1 2024 to June 30 2025
$
160.00
AVFD Ambulance Only
July 1 2024 to June 30 2025
$
95.00
Donation
If you'd like to include a donation, select an amount from the drop-down list. Thank you for supporting your local ambulance service!
$
100.00
Donation Amount
$100 Donation
$75 Donation
$50 Donation
$25 Donation
$200 Donation
$500 Donation
$1000 Donation
$2000 Donation
Please type your name and date to accept the Terms and Conditions
*
Please read the terms (above) carefully before typing your name so as to acknowledge that you have reviewed and agree to abide by the terms and conditions of each provider as described above and in the following sections of this Agreement.
Important Credit Card Payment Information
Please note that credit card payments are processed through PayPal and may appear on your credit card statement as a PayPal transaction.
Payment Methods
Debit or Credit Card
Please click one of the PayPal options to complete payment and
submit
the form.
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