CTGR FireMed Membership Application (Tribal Members)

FireMed Enrollment for Tribal Members

If enrolling during open season (September - October), memberships are valid November 1st - October 31st of the upcoming benefit period. If enrolling outside of open season, memberships are valid two days after application is received until October 31st of the current benefit period. Memberships apply to residents served by the Grand Ronde Tribal Emergency Services Department. If you have questions, please call (800) 238-9398.

Primary Member Contact Information

Name*

First NameMiddle InitialLast NameSuffix

Date of Birth*

MonthDayYear

Tribal Membership Number*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Mailing Address (if different from home address)

Mailing Address

Street Address (or P.O. Box)

Street Address Line 2

CityState / Province

Postal / Zip Code

I have eligible dependents living in my household that I would like to register for FireMed. (Please refer to the Terms of Agreement for the definition of eligible dependent.)*

Other Household Members

Please list all eligible dependents living in the household.

Dependent 1 Name

First NameMiddle InitialLast NameSuffix

Dependent 1 Date of Birth

MonthDayYear

Dependent 2 Name

First NameMiddle InitialLast NameSuffix

Dependent 2 Date of Birth

MonthDayYear

Dependent 3 Name

First NameMiddle InitialLast NameSuffix

Dependent 3 Date of Birth

MonthDayYear

Dependent 4 Name

First NameMiddle InitialLast NameSuffix

Dependent 4 Date of Birth

MonthDayYear

Dependent 5 Name

First NameMiddle InitialLast NameSuffix

Dependent 5 Date of Birth

MonthDayYear

Dependent 6 Name

First NameMiddle InitialLast NameSuffix

Dependent 6 Date of Birth

MonthDayYear

Dependent 7 Name

First NameMiddle InitialLast NameSuffix

Dependent 7 Date of Birth

MonthDayYear

Dependent 8 Name

First NameMiddle InitialLast NameSuffix

Dependent 8 Date of Birth

MonthDayYear