Membership | Susquehanna Township EMS

Enroll for your 2019-2020 STEMS Ambulance Membership Below!

Last Name*

First Name*

Date of Birth*

Name (2)

Date of Birth (2)

Name (3)

Date of Birth (3)

Name (4)

Date of Birth (4)

Name (5)

Date of Birth (5)

Name (6)

Date of Birth (6)

Name (7)

Date of Birth (7)

Please Select Membership Type:*

$50 Individual Membership
$60 Couple Membership
$75 Family Membership

The Cost of Each Membership is listed with the Membership Type.

Donation

Any Donation submitted is in addition to Cost of the Ambulance Membership you have selected. STEMS always welcomes donations of any kind to help support our 24/7 Emergency Operations! You may also make your donation to STEMS at https://www.stems.us/contributions/

Address*

Street Address Address Line 2 City State ZIP Code

Township/Borough*

Susquehanna Township
Paxtang Borough
Pennbrook Borough

Please select the Municipality where you residence is located.

Daytime Phone*

Email

Susquehanna EMS reserves the right to bill any available third party benefits.
Please list ALL dependents that you include on your federal income tax.

Authorization

I request that payment of any authorized insurance benefits be made either to me or on my behalf to Susquehanna Twp EMS for any services furnished by this health service provider or supplier. I authorize any holder of medical information about me to release to the Center for Medicare Services and its agent any information needed to determine these benefits or the benefits payable for related services. I also understand, that I am still requirement to make payment of all Copayments and Coinsurances as established by the terms of my health insurance policy.

Authorized Signature*

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Membership Enrollment

STEMS Membership Enrollment

Authorization