I hearby apply for memebership for my dependants and myself as listed on this application. I certify we are and will remain covered by health insurance policy for the full time of this membership.

   I transfer directly to Del Norte Ambulance, Inc. my rights to insurance payments, for other applicable coverage due me.

   I understand that after my deductable is met, Del Norte Ambulance will accept insurance payment from my insurance carrier as payment in full.

   In the event my insurance does not cover service, I will recieve a 10% discount for prompt payment.

   The above information is true to the best of my knowledge. I understand any falsifications may result in denial of Association Membership. I hearby authorize any company, agency, or facility to release any and all information pertinent to this membership about myself and my dependants listed above to Del Norte Ambulance, Inc.

   Air service may be unavailable due to FAA Regulations or acts of God, without notice.