Form Center

Search Forms:

Search Forms Select a Category

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

RescueCare Membership Application

Steps

1. Household Addresses This section is complete This section is incomplete
2. Household Members This section is complete This section is incomplete
3. Agreement Terms & Signature This section is complete This section is incomplete

Household Addresses

Membership period of July 1st through June 30th
If a member needs ambulance treatment or transport, RescueCare will bill any insurance carrier and consider whatever insurance pays as payment in full. Your membership fee covers everything else.
Street Address*
City*
State*
Zip Code*
Mailing Address
Complete if different from your Street Address.
City
State
Zip Code
Continue

Household Members

Household Members
A membership in RescueCare includes all persons who are permanent residents of the same single-family (non-commercial) dwelling within the City’s ambulance service area, living together as part of a family unit, but excluding roomers or boarders. Membership also includes household members living in substitute care. For details, please check the agreement terms for a further definition.
1. First Name*
Last Name*
Date of Birth*
Date of Birth
2. First Name
Last Name
Date of Birth
Date of Birth
3. First Name
Last Name
Date of Birth
Date of Birth
4. First Name
Last Name
Date of Birth
Date of Birth
Continue |Go Back

Agreement Terms & Signature

RescueCare Agreement Terms
RescueCare Agreement Terms Page
A signature on this application constitutes your acceptance of all the RescueCare Agreement Terms; be sure to carefully review the Agreement Terms prior to electronically signing and submitting your application for membership.
Payment
Your payment ($59 inside city limits or $185 outside city limits) must accompany this application.
Signature*
Date*
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit | Go Back

Form Center

Search Forms:

RescueCare Membership Application

Steps

Household Addresses

Household Members

Agreement Terms & Signature

Contact Us

Quick Links

Helpful Links