Ambulance Subscription / EMS Donations

If you have any questions about this form please contact Dave Weis Ph: (717) 993-6180 x103 or email ems54manager@outlook.com .

PLEASE NOTE:

If you are looking for an Ambulance Subscription please select one of the options in the drop down menu below. If you would like to make a General Donations instead, please enter your amount in the optional field below. We invite you to do both!

First Name:

Last Name:

Address:

Township or Borough:

City:

State:

Zipcode:

Email:

Best Contact Number:

Reference # (optional)

Ambulance Membership Suggested Donations:

General Donation Amount $

Total Donation $

Please check this box if we need to update our records to match this form

* required field

Please complete the item(s) outlined in red.