Membership | Susquehanna Township EMS

Get your 2018-2019 STEMS Ambulance Membership Below!

Last Name*

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)

Membership Type:*

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

Donation

STEMS always welcomes donations of any kind to help support our 24/7 Emergency Operations!

Address*

Street Address Address Line 2 City State ZIP Code

Township/Borough*

Susquehanna Township
Paxtang Borough
Pennbrook Borough

Daytime Phone*

Email

Susquehanna EMS reserves the right to 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.

Authorized Signature*

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Membership Enrollment

Membership Enrollment

Authorization