Join FireMed Printable Enrollment Form

To change any item, go to the appropriate Step and make update. When finished, go to Step 7 to confirm & pay.

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

FireMed Plus

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

$ 115 /year

Step 2: User Information (!)

That email is already registered. Click here to renew

Verify Email Address

Passwords must be at least 6 characters long.

Password *

Verify Password *

Step 3: Personal Information (!)

First Name *

Last Name *

Member Date of Birth (mm/dd/yyyy) *

Phone and Alternative Phone, if available *

How did you hear about FireMed? *

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 *

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

Mailing Zip

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.

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

Enter Code

Step 6: Payment Information (!)

Credit Card Billing Address Same as Home

Credit Card Billing Address *

Billing City *

Billing State

Billing Zip *

Billing First Name *

Billing MI

Billing Last Name *

Credit Card Number (no dashes or spaces): *

Exp Month

Exp Year:

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!

Step 7: Order Summary

Home Address (Residence):

Address:
City:
State:
Zip:

Mailing Address:

Address:
City:
State:
Zip:

FireMed Basic

$65.00

Total

$65.00

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