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.

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

FireMed Basic

Ambulance

Full emergency ambulance coverage for your entire household.

$ 65 /year

FireMed Plus

Ambulance + Ambulance

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

$ 115 /year

Passwords must be at least 6 characters long.

First name is required.
Last Name *
Last name is required.
Date of birth is required.
Phone is required.
Required.

Address is required.
City is required.
State is required.

Address is required.
City is required.

Zip is required.

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 the + sign to enter additional household members. If no other members apply, continue to next step.



Address is required.

City is required.


Zip is required.

First name is required.
Last name is required.

Credit card number is required.



CVV is required.


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


Home Address (Residence):




Mailing Address:






FireMed Basic
$65.00

Total
$65.00
loading..
Processing