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Thank you for your interest in a Life Flight Network Membership.

By becoming a Life Flight Network member, you agree to the terms stated in the Statement of Understanding. New member benefits take effect 72 hours after receipt of completed application and payment. Life Flight Network transports patients based on medical need, not membership status. Medicaid beneficiaries should not apply for membership.

This form is hosted on our secure server and all information is encrypted using SSL for your personal data privacy and security.


Note: All fields with (*) are required, even if renewing, in order to ensure our records are up to date.

Membership Information


Please Select
If renewing membership, enter Membership ID Invalid Input

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By selecting the auto renew option, I authorize Life Flight Network to make annual recurring payments to the credit card provided. See further details at bottom of this form.**

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Member Information

Primary Member First Name* You must enter a first name.
Last Name* You must enter a last name.
Date of Birth (mm/dd/yyyy)* Invalid Input
Spouse/Domestic Partner Invalid Input
Date of Birth (mm/dd/yyyy) Invalid Input
Mailing Address* You must supply an address.
City* You must supply a city.
State*Please select a state.
Zip Code*You must supply a zip code.
Phone*You must supply a phone number.
Email*You must provide an email address.

(Will be used to provide confirmation of membership payment as well as sign you up for our membership Enewsletter)


Dependents are defined as unmarried dependents you claim on your income tax return.

NameDate of Birth (mm/dd/yyyy)
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Please call our membership office if you have additional dependents to add.

Gift Information (if applicable)

Gift Giver NameInvalid Input
Mailing AddressInvalid Input
CityInvalid Input
StateInvalid Input
Zip CodeInvalid Input
PhoneInvalid Input
EmailYou must provide an email address.
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Other Information

How did you hear about Life Flight Network Membership?*
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If Other, please specify:
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Payment Information

Credit Card Type*
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Please press PROCEED TO PAYMENT only once to ensure proper processing of your information. Clicking "Proceed to Payment" will redirect you to Life Flight Network's secure payment system, where you can complete your order using your credit card or PayPal account. Membership purchases are non refundable and non transferable.

**If renewing membership automatically: I hereby authorize my financial institution to make annual recurring payments from the credit card account listed above up to 1 month prior to my expiration date in the amount indicated on this form for a 1 year membership. I will notify Life Flight Network in writing if I decide to discontinue this service or change or close my credit card account. I certify that I am an authorized user of this credit card and will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.