Join FireMed Printable Enrollment Form

Please complete your information on each step. Fields with a red * are required fields. After reviewing your information on the Order Summary step, click ‘Confirm & Pay’ or correct any error message noted in red.
To change any item, go to the appropriate Step and make update. When finished, go to the Order Summary step, review, and click ‘Confirm & Pay’. A confirmation message will appear when the order is successfully submitted.

Step 1: Choose Your Membership

Choose which package you would like, or learn more about your membership options.

FireMed Basic

Full emergency ambulance coverage for your entire household.

$ 65 /year

Choose this plan

FireMed Plus

+

Full emergency ambulance coverage for your entire household, plus Life Flight Network.

$ 115 /year

Choose this plan

Next

Step 2: User Information (!)

That email is already registered. Click here to renew

Email

Verify Email Address

Emails Match!

Emails must match.

Passwords must be at least 6 characters long.

Password

Verify Password

Password Matches!

Passwords must match.

Next

Step 3: Personal Information (!)

First Name

MI

Last Name

Member Date of Birth (mm/dd/yyyy)

Phone and Alternative Phone, if available

How did you hear about FireMed?

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Home Address (Residence): If your residential zip code does not appear, please call 541-726-3636 instead of using this form.

Home City

Home State

Home Zip

97401 97402 97403 97404 97405 97408 97409 97412 97413 97419 97431 97437 97438 97446 97448 97452 97454 97455 97461 97477 97478 97487 97488 97489 97490

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Checkmark box if your Mailing Address is the same as your Home Address

Mailing Address (if FireMed mail should be sent to different address than above)

Mailing City

Mailing State
Armed Forces (AA) Armed Forces (AE) Alaska Alabama Armed Forces (AP) Arkansas Arizona California Colorado ConnecticutUS Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Mailing Zip

Next

Step 4: Add Family Members

Include all additional persons who are primary residents of the same single-family occupancy, non-commercial residence, living together as a family unit, but not to include roomers or boarders.

Click Add Member sign to enter additional household members. If no other members apply, continue to next step.

Add Member

Remove Member

ID

Firemed Member ID

First Name

M.I.

Last Name

DOB (mm/dd/yyyy)

Next

Step 5: Employer or UO Student Discount Code (if applicable)

Enter Code

Click here for Discount

The Code is invalid or has expired.

The Discount was successfully added.

Next

Step 6: Payment Information (!)

Credit Card Billing Address Same as Home

Credit Card Billing Address

Billing City

Billing State
Armed Forces (AA) Armed Forces (AE) Alaska Alabama Armed Forces (AP) Arkansas Arizona California Colorado ConnecticutUS Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Billing Zip

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Billing First Name

Billing MI

Billing Last Name

Credit Card Number (no dashes or spaces):

Exp Month
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Exp Year:
2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

CVV:

Would you like to add a Donation? Please enter the amount here

Donations are used to provide membership scholarships to low income citizens. Thank you for your help!

Next

Step 7: Order Summary

You must fix the following errors before you can submit the form.

Home Address (Residence):

Address:
City:
State:
Zip:

Mailing Address:

Address:
City:
State:
Zip:

Family Members

All fields for each family member must be filled out before submitting the form.

First Name	MI	Last Name	DOB

FireMed Basic

$65.00

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Signup Donation

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Promo Code Discount

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Total

$65.00