2023 Annual Donation Drive 

Individual $35.00

Household $75.00

Business $150.00

Business enrollment is $150.00 for the first twenty-five (25) employees, plus an additional $75.00 for each twenty-five (25) employees above that staff size.

We certainly hope that we can count on your contribution again this year. It is greatly appreciated and needed so that we can continue to provide the highest quality emergency medical and rescue services when you need them.

Your contribution entitles you to:

· Emergency and non-emergency ambulance transport to any hospital within 100 miles of  Charlestown, when requested by police, physicians, or appropriate 911 calls and when service is provided by Charlestown Ambulance-Rescue Service Inc.

· We will bill your insurance, but any remaining balance will be waived.

Important Information

· This program is available to residents and property owners in the Charlestown area.

· Non-emergency transports:

· Must be medically necessary and authorized by a physician.

· Must be scheduled 24 hours in advance.

· Subject to available personnel and equipment.

· Elective procedures, doctor office visits, or ongoing treatment such as dialysis, chemo, or radiation therapy are not included.

· Subscriptions start in March and extend for one (1) year.

· Contributions received after March are not pro-rated.

*Subscriptions are not insurance coverage*

Indicates Required Field

Date/Time:		04/19/2024 0301
Name:
Date of Birth (MM/DD/YYYY):
Email Address:
House Number:
Street Name:
Address Line 2:
Town:
Zip Code:
Phone Number:
Name of Family Member #1:
Date of Birth of Family Member #1:
Name of Family Member #2:
Date of Birth of Family Member #2:
Name of Family Member #3:
Date of Birth of Family Member #3:
Name of Family Member #4:
Date of Birth of Family Member #4:
Name of Family Member #5:
Date of Birth of Family Member #5:
Donation Amount:		$35 Single $75 Family $150 Business
Upon Successful completion of this form you will be directed to PayPal to submit payment.