Join FireMed Printable Enrollment Form

To change any item, go to the appropriate Step and make update. When finished, go to Step 6 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.

$ 55 through 10/31/2017

FireMed Plus

Full emergency ambulance coverage for your entire household, plus Mercy Flights.

$ 99 through 10/31/2017

Step 2: User Information

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

Home Address (Residence): If your residential zip code does not appear, please call 541-488-6009 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 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.

Step 5: 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:

Exp Month

Exp Year:

CVV:

Would you like to add a Donation for Ashland Fire & Rescue? Please enter the amount here.

Step 6: 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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