TEAM Application Form

T·E·A·M Application
Please complete this application in full to enroll yourself and, if applicable, your household members or legal dependents.

If you are purchasing a membership as a gift, please enter your own information first. Then, add the recipient and their household members in the Additional household members section.

If you have any questions, please call 503-815-2257 for assistance. You can also visit AdventistHealthTillamook.org/TEAM for more detailed information about this program.
Your information
Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Sex
Your email
Additional household members

Fill out all fields for each household member you are adding.
How many additional household members would you like to add?
Name 1

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Sex
Name 2

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Sex
Name 3

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Sex
Name 4

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Sex
Name 5

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Sex
Home address
Address (line 1)
Address (line 2)
City
State
Zip code
Your phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance name
If you have no insurance, enter none.
Please review and check off each statement to show you understand the program details.

This TEAM membership covers my portion of the expense of ambulance service if provided by Adventist Health Tillamook Ambulance Services including: 1) Emergency evaluation and first aid if not transported; 2) Emergency care provided at the scene of an accident or illness; 3) Transportation to the nearest appropriate facility; 4) Medically necessary or pre-approved transports from one facility to another, including those out of our service area; and 5) Any supplies or medications used by the ambulance personnel.
Choose your T·E·A·M membership type

Choose your preferred membership period

1-year membership

$60.00

2-year membership

$100.00

Lifetime membership

$1,200.00

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

T·E·A·M Application

Your information

Additional household members

Home address

Choose your preferred membership period