FireMed Application

Annual membership begins November 1st of each year and expires on October 31st each year. Open enrollment for FireMed runs from Sept to October. Any applications received outside of this open enrollment period will be subject to a 2 day waiting period from the time payment is received.

To become a FireMed Member, follow the three steps below.

1. Read the document below.

Fire Med Terms and Conditions.pdf

2. Fill out this application form.

Primary Member's First Name (required)

Primary Member's Last Name (required)

Primary Member's Date of Birth (required)

Street Address (Please do not use a PO Box or other mailing address here.) (required)

Mailing Address (If different than street address.)

Phone Number (required)

Email Address (required)

Additional Members? You may add a spouse (by marriage or domestic partnership only) and any children in the house hold under 21 that are unmarried and the primary member claims as a dependent. See membership terms for more details. (required)

In this box please list all additional members. You must include their full legal name, date of birth, and relationship to the primary member or they will not be added to the membership.

I have read and acknowledge all terms and conditions in the document above. (required)

I agree.

I understand that my membership is not valid unless payment is made to accompany this form. (required)

I understand.

Signature of Primary Member (Please type full legal name.) (required)

Date (required)

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3. Click here to pay for your membership.