FireMed Application - South Lane County Fire and Rescue

Enter primary member/head of household information here.

First Name(*)

Please type your first name.

Last Name(*)

Please type your last name.

Address Number(*)

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Street(*)

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City(*)

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Zip Code(*)

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Date of Birth(*)

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mm/dd/yyyy

Telephone(*)

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Email Address(*)

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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.

Number of Household Members. (*)

Please tell us how many family members live in your household.

Number of household members.

Household Member 1

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Relationship

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Date of Birth

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mm/dd/yyyy

Household Member 2

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Relationship

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Date of Birth

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mm/dd/yyyy

Household Member 3

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Relationship

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Date of Birth

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mm/dd/yyyy

Household Member 4

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Relationship

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Date of Birth

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mm/dd/yyyy

Household Member 5

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Relationship

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Date of Birth

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mm/dd/yyyy

Household Member 6

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Relationship

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Date of Birth

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mm/dd/yyyy

Household Member 7

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Relationship

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Date of Birth

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mm/dd/yyyy

Please select a FireMed Membership Level. Payment is by Secure Credit Card processing by PayPal (no PayPal account required).

Select a membership level(*)

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Ground Ambulance Only is $65 per year. Ground Ambulance + Air Transport is $140 per year. Life Flight Air Ambulance Only is $85 per year. Membership is valid 24 hours following application submission to June 30.

Total (Pay by Credit Card)

0.00 USD

When you click "submit," you will be redirected to PayPal for secure credit card processing. No PayPal account is required. You will receive an email confirmation of your application and payment once payment is processed.

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South Lane County Fire & Rescue: FireMed Application

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