The Westerly Ambulance Corps, Inc.
The Westerly Ambulance Corps, Inc
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2018 Incidents
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Feb 531
Mar 582
Apr 522
May 589
Jun 588
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Total 3382


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Subscription Membership 2018

Westerly Ambulance Corps, Inc., is a non-profit, volunteer based organization that has served the citizens of the Greater Westerly Pawcatuck area since 1917. Please complete the information below to complete your subscription membership contribution for the year 2018. The cost of this membership is $60.00** Payment can be made by: * Mailing a check with a copy of your completed subscription membership form to 30 Chestnut Street, Westerly RI 02891 ** Paying by credit card online or at our headquarters. This method carries a surcharge of $1.50. * Paying with cash at our headquarters from 9am-5pm Monday through Friday

Required   Indicates Required Field
WAC Subscription Account Number:
Head of Household Name: Required
Head of Household Gender: Required Male
Female
Head of Household Date of Birth: Required
Street Address: Required
Town/State/Zip Code: Required
Telephone Number with Area Code:
Email Address:
Dependant Information
Legal Spouse Name:
Legal Spouse Gender: Male
Female
Legal Spouse Date of Birth:
Dependent Child #1 Name:
Dependant Child #1: 17 Years of age or younger
A full-time student who resides with you and is 24 years of age or younger.
Dependant Child #1 Gender: Male
Female
Dependant Child #1 Date of Birth:
Dependant Child #2 Name:
Dependant Child #2: 17 Years of age or younger
A full-time student who resides with you and is 24 years of age or younger.
Dependant Child #2 Gender: Male
Female
Dependant Child #2 Date of Birth:
Dependant Child #3 Name:
Dependant Child #3: 17 Years of age or younger
A full-time student who resides with you and is 24 years of age or younger.
Dependant Child #3 Gender: Male
Female
Dependant Child #3 Date of Birth:
Additonal Dependants Residing with you?? If you fill in their name, gender and date of birth in text box below:
AFTER COMPLETING THIS FORM BY HITTING THE SUBMIT BUTTON BELOW; PAYMENT MUST BE SUBMITTED THROUGH THE WEBSITE BY USING THE BUY NOW BUTTON ON SUBSCRIPTION MEMBERSHIP PAGE OR BY MAILING A CHECK TO WESTERLY AMBULANCE.
Your Contribution as a current subscription member entitles you to: * Emergency and non-emergency ambulance transport to any hospital within 75 miles of Westerly when requested by police, physicians or appropriate 911 calls and when service is provided by The Westerly Ambulance Corps. * Service MUST originate in Rhode Island. * We will bill your insurance, but any remaining balance will be waived. Other Important Information: * Program is available to residents and property owners in Westerly, RI. * Non- Emergency Transports MUST: - Medically necessary and authorized by a physician - Scheduled in advance with Westerly Ambulance - Subject to availability of ambulance and staff - Elective procedures, doctor's office visits or ongoing treatments such as but not limited to dialysis, chemo are radiation therapies are not included. **The Subscription membership program runs from March 1, 2018 until March 1, 2019. Any applications received after March 1, 2018 will be subject to a waiting period of 30 days and the cost of the membership will not be prorated.** In Case of Emergency Dial 911




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The Westerly Ambulance Corps, Inc.
30 Chestnut Street
Westerly, RI 02891
Emergency Dial 911
Administrative Phone: 401-596-4375 ext. 0
Station Fax: 401-596-8942
E-mail: info@westerlyambulance.org
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