Westerly Ambulance Corps, Inc. · Subscription Memberships

Subscription Membership 2024

The 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 2024.

The cost of this membership is $80.00 **

Payment can be made by:

Mailing a check with a copy of your completed subscription membership form to:
30 Chestnut Street, Westerly RI 02891.
Credit Card online or at our headquarters
**This method of payment carries a surcharge of $1.50.
Cash payments are accepted at our headquarters from 9am-4pm Monday-Friday.

Questions? Contact us at (401) 596-4375 Ext. 203 or at www.westerlyambulance.org

WAC Subscription Account Number (if known)

Head of Household Name

First Name

Last Name

Head of Household Gender

Male

Female

Head of Household Date of Birth

(mm/dd/yyyy)

Email Address

Verify Email

Household Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Is your mailing address different than your household address?

Yes

Mailing Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Dependents

Please list legal spouse and children 17 years old or younger, or a full-time student under the age of 24 that resides with you.

Other members of your household need their own subscription membership.

Spouse

Add Legal Spouse?

Yes

Legal Spouse Name

First Name

Last Name

Legal Spouse Gender

Male

Female

Legal Spouse Date of Birth

(mm/dd/yyyy)

Children

Dependent Child #1 Name

First Name

Last Name

Dependent Child #1 is:

17 Years of age or younger

A full-time student who resides with you and is 24 years of age or younger

Dependent Child #1 Gender

Male

Female

Dependent Child #1 Date of Birth

(mm/dd/yyyy)

Dependent Child #2 Name

First Name

Last Name

Dependent Child #2 is:

17 Years of age or younger

A full-time student who resides with you and is 24 years of age or younger

Dependent Child #2 Gender

Male

Female

Dependent Child #2 Date of Birth

(mm/dd/yyyy)

Dependent Child #3 Name

First Name

Last Name

Dependent Child #3 is:

17 Years of age or younger

A full-time student who resides with you and is 24 years of age or younger

Dependent Child #3 Gender

Male

Female

Dependent Child #3 Date of Birth

(mm/dd/yyyy)

Dependent Child #4 Name

First Name

Last Name

Dependent Child #4 is:

17 Years of age or younger

A full-time student who resides with you and is 24 years of age or younger

Dependent Child #4 Gender

Male

Female

Dependent Child #4 Date of Birth

(mm/dd/yyyy)

Additional Dependents

Please provide their name, gender and date of birth:

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., Inc. Service must originate in Rhode Island.
We will bill your insurance, but any remaining balance will be waived.

Important Information:

Program is available to residents and property owners in the Westerly, RI.
Non-emergency transports:
- Must be medically necessary and authorized by a physician
- Must be scheduled 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
Subscription starts March 1, 2024 and extends for one (1) year.
Open Enrollment for 2024, however payments are not pro-rated.

After clicking the Submit button, please follow the instructions to save your registration details and to submit your payment.

In Case of Emergency Dial 911