Application

FireMed Ambulance Membership Program

FireMed membership includes all persons who are permanent residents of the same single family occupancy, non-commercial residence within the Hermiston Fire and Emergency Services ambulance district, living together as part of a family unit, but not to include mere roomers or boarders. Membership is also extended to include household members living in substitute care.

Number of Household Members:
Household Information
First Name:*
Middle Initial:
Last Name:*
Address*
Street AddressAddress Line 2CityStateZip Code
Phone
Email
Mailing Address (if different than above)
Address
Street AddressAddress Line 2CityStateZip Code
Household Member #2:
First Name:
Middle Initial:
Last Name:
Household Member #3:
First Name:
Middle Initial:
Last Name:
Household Member #4:
First Name:
Middle Initial:
Last Name:
Household Member #5:
First Name:
Middle Initial:
Last Name:
Household Member #6:
First Name:
Middle Initial:
Last Name:
Household Member #7:
First Name:
Middle Initial:
Last Name:
Household Member #8:
First Name:
Middle Initial:
Last Name:
Household Member #9:
First Name:
Middle Initial:
Last Name:
Household Member #10:
First Name:
Middle Initial:
Last Name:
Household Member #11:
First Name:
Middle Initial:
Last Name:
Household Member 12:
First Name:
Middle Initial:
Last Name:
Household Member 13:
First Name:
Middle Initial:
Last Name:
Household Member 14:
First Name:
Middle Initial:
Last Name:
Household Member 15:
First Name:
Middle Initial:
Last Name:
Total:
If you have any questions or need assistance with this form or payment please contact us here.
Type of FireMed*
- FireMed only ($51)
- FireMed + Life Flight($108)

Hermiston Fire & Emergency Services

Leading Eastern Oregon in fire & EMS

Application

FireMed Ambulance Membership Program

Household Information

Mailing Address (if different than above)

Household Member #2:

Household Member #3:

Household Member #4:

Household Member #5:

Household Member #6:

Household Member #7:

Household Member #8:

Household Member #9:

Household Member #10:

Household Member #11:

Household Member 12:

Household Member 13:

Household Member 14:

Household Member 15:

Total: