Family Subscription Plans

Choose Only 1 Subscription Plan: Unless You're Purchasing For Multiple Households.

Option 1: Family Subscription

This subscription covers you and your family from August 1, 2026 to July 31, 2027

• Up to three emergency transports to the nearest appropriate medical facility for all subscribed household members.

• Billing & collection of benefits available from the subscribers’ medical insurance on behalf of the subscriber.

• Subscribers will not be billed for any portion of our fees (deductibles/copayments) not covered by their insurance.

• A subscription is not necessary for recipients of Medicaid or uninsured residents.

$60.00 Quantity
Item subtotal:

*NEW* Option 2: Family Subscription PLUS

Includes everything the Family Subscription covers PLUS

• 1 medically necessary interfacility transport (transport between hospitals/rehab/nursing home or to their home) deemed necessary by a Physician.

*Transfers are per household, not per family member

$100.00 Quantity
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Additional Donation

Use the quantity box to increase your tax deductible donation amount.

$1.00

$0	Quantity	Price
Increments of 1		$1.00
Increments of 10		$10.00
Increments of 25		$25.00
Increments of 100		$100.00

Item subtotal:

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Name

First NameLast Name

Family Members Living In Your Household:

Please list all family members living in your household and their relationship to you

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signature

By submitting this form, I understand I am signing up for a Waterbury Ambulance Service, Inc. Subscription covering all people living within my house. I understand that the $60/$100 per household fee is not prorated and that EMS will provide unlimited pre-hospital emergency care, when medically necessary, to me and my listed household members within the primary service area covered by Waterbury Ambulance Service, Inc regardless of participation in this program. The subscription will begin on July 1, 2026 and end June 30, 2027. This subscription is terminated if the subscriber moves outside Waterbury Ambulance Service, Inc.'s primary service area.

I understand that if any member of my household uses services of Waterbury Ambulance Service, Inc., a bill will be sent to my insurance company and that I will not be responsible for a co-payment or deductible. Any payment I receive directly from my insurance company must be forwarded to Waterbury Ambulance Service, Inc. This subscription is non-refundable and non-transferable. I authorize payment of medical benefits to Waterbury Ambulance Service, Inc.

The $60/$100 fee for the family subscription or family subscription PLUS program is not tax-deductible. Any addition donations are tax deductible!

Family Subscription Plans

Choose Only 1 Subscription Plan: Unless You're Purchasing For Multiple Households.*

Choose Only 1 Subscription Plan: Unless You're Purchasing For Multiple Households.