Ambulance Membership

2026-2027 Ambulance Membership Application

AVFD only -or- AVFD + AirMedCare
Contact Information
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Full Name

First NameLast Name
Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Check if
Primary Member Name (if different than above)

First NameLast Name
Primary Member Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState

Zip Code
Primary Member Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Family Members

These include the primary member's spouse or partner, other immediate family members living at the same residence, and dependent children away at school. Memberships are for named persons only and are not transferable. Please contact us with questions or concerns about these definitions.
List additional family members in the household here:
Ambulance and AirMedCare Membership Enrollment

A completed Agreement is required for any option. Please take time to read and fill out completely; an incomplete application may delay your coverage. Prices shown below are for annual membership for you and your Other Family Members listed above. Please check one or more boxes.
Select your membership
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AVFD + AirMedCare
Combination Membership July 1 2026 to June 30 2027

$160.00



AVFD Ambulance Only
July 1 2026 to June 30 2027

$95.00



Donation
If you'd like to include a donation, select an amount from the drop-down list. Thank you for supporting your local ambulance service!

$100.00 Donation Amount



Total

$0.00
Please type your name and date to accept the Terms and Conditions
Please read the terms (above) carefully before typing your name so as to acknowledge that you have reviewed and agree to abide by the terms and conditions of each provider as described above and in the following sections of this Agreement.
Important Credit Card Payment Information

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Payment Methods

Debit or Credit Card

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2026-2027 Ambulance Membership Application

Contact Information

Additional Family Members

Ambulance and AirMedCare Membership Enrollment

Select your membership *

Important Credit Card Payment Information

Payment Methods

Select your membership