South Lane County Fire & Rescue: FireMed Application
  1. Enter primary member/head of household information here.
  2. First Name(*)
    Please type your first name.
  3. Last Name(*)
    Please type your last name.
  4. Address Number(*)
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  5. Street(*)
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  6. City(*)
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  7. Zip Code(*)
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  8. Date of Birth(*)
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    mm/dd/yyyy
  9. E-mail(*)
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  10. Telephone(*)
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  11.  
  1. Please list other household members, if any. Include the totals number of household members living at this residence to be covered by the FireMed Membership. If you are the only member of the household, please indicate this by selecting "1" as the total number of household members.
  2. Number of Household Members. (*)
    Please tell us how many family members live in your household.
    Number of household members.
  3. Household Member 1
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  4. Date of Birth
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    mm/dd/yyyy
  5. Household Member 2
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  6. Date of Birth
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    mm/dd/yyyy
  7. Household Member 3
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  8. Date of Birth
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    mm/dd/yyyy
  9. Household Member 4
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  10. Date of Birth
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    mm/dd/yyyy
  11. Household Member 5
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  12. Date of Birth
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    mm/dd/yyyy
  13. Household Member 6
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  14. Date of Birth
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    mm/dd/yyyy
  15. Household Member 7
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  16. Date of Birth
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    mm/dd/yyyy
  17.  
  1. Insurance Information (optional)
  2. Primary Insurance Company
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  3. Insurance ID Number
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  4.  
  1. Please select a FireMed Membership Level. Payment is by Secure Credit Card processing by PayPal (no PayPal account required).
  2. Pay by Credit Card.(*)
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    Ground Ambulance Only is $62 per year. Ground Ambulance + Air Transport is $107 per year. Life Flight Air Ambulance Only is $65 per year.
  3. Total
    0.00 USD
  4.   
  5. This form is under construction. PayPal is in LIVE mode and payment WILL be collected. Forms are submitted for testing only and applications will not be processed.

Contact Us

Administration and Headquarters
233 Harrison Ave
Cottage Grove, OR 97424
tel: (541) 942-4493
fax: (541) 942-3367

Business Hours: 8 am to 5 pm Mon-Fri

Emergency Dial 911

FireMed: Join Today!

FireMed LogoA ground ambulance transport in the Eugene-Springfield area will cost more than $1,800, and an air ambulance more than $18,000, unless you have FireMed! Health insurance may cover 20-50%. FireMed members pay NOTHING, even if they have no insurance, and your membership covers your whole household. Learn more...

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