Clone of 2025/2026 Subscription Plan Enrollment or Renewal

Rescue Inc Subscription Membership Application/Renewal

Coverage Period: July 1, 2026 - Midnight June 30, 2027
Head of Household Information

First NameLast NameDate of Birth
Number of additional household members
Name and Date of Birth for all additional persons legally, permanently residing at the address below who will be covered under this membership
First NameLast NameDate of Birth
First NameLast NameDate of Birth
First NameLast NameDate of Birth
First NameLast NameDate of Birth
First NameLast NameDate of Birth
First NameLast NameDate of Birth
E-mail
For periodic newsletters and information regarding Rescue Inc. We do not share this information.
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I am including an additional donation of (optional)
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USDTotal to be charged

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Terms and Conditions: Membership in Rescue Inc.’s Subscription Program entitles benefits to the subscriber and any enrolled individual legally and permanently residing in the same household. Active benefits begin upon receipt of the application and fee payment on July 1, 2025, whichever is later. Rescue Inc. reserves the right to bill and receive payment from your insurance carrier. Payments made directly to you by your insurance carrier for services covered under this agreement are to be forwarded to Rescue Inc. Memberships cannot be prorated. Note: Local facilities (depending upon pick-up point) are Brattleboro Memorial Hospital, Grace Cottage Hospital, or Cheshire Medical Center.
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Rescue Inc Subscription Membership Application/Renewal