MiREMS First Responder Agency Membership Application

Membership supports MiREMS’ mission to strengthen rural EMS systems across Michigan through training, collaboration, and resource development. Michigan Rural EMS Network (MiREMS) agency membership is available to first responder agencies that provide or support emergency medical services.

Please complete the form below to enroll your agency. After submission, MiREMS will follow up with an invoice and onboarding information.

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1. Agency Name (Required.)

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2. Agency Type (Required.)

Transporting ALS/BLS

Fire Department With Transport

Fire Department Without Transport

Other

Other (please specify)

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3. Agency Address (Required.)

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4. Primary Agency Representative (this individual will be given voting rights at MiREMS membership meetings) (Required.)

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5. Primary Representative Phone (Required.)

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6. Primary Representative Email

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7. Is the primary representative also the billing contact? (Required.)

Yes

If no, please enter contact for billing (include name, phone, email)

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8. Approximate number of agency employees (Required.)

1-10

11-25

26-50

51+

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9. Agency staffing model (Required.)

Career

Paid on call

Combination

Volunteer

Other (please specify)

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10. Requested membership level (Required.)

Standard Agency Membership - $500/year

Enhanced Agency Membership - $1200/year

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11. Payment preference (for invoicing purposes) (Required.)

Check

PayPal (if using PayPal, a 3.5% fee will be added to your invoice)

Other (please specify)

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12. Acknowledgement (Required.)

I understand that MiREMS membership is invoiced annually and that MiREMS, upon completed application, will follow up with the designated representative to confirm payment instructions and onboarding information.

MiREMS First Responder Agency Membership Application

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* 1. Agency Name (Required.)

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* 2. Agency Type (Required.)

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* 3. Agency Address (Required.)

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* 4. Primary Agency Representative (this individual will be given voting rights at MiREMS membership meetings) (Required.)

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* 5. Primary Representative Phone (Required.)

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* 6. Primary Representative Email

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* 7. Is the primary representative also the billing contact? (Required.)

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* 8. Approximate number of agency employees (Required.)

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* 9. Agency staffing model (Required.)

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* 10. Requested membership level (Required.)

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* 11. Payment preference (for invoicing purposes) (Required.)

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* 12. Acknowledgement (Required.)

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* 13. Is there anything additional you would like MiREMS to know about your agency?

1. Agency Name (Required.)

2. Agency Type (Required.)

3. Agency Address (Required.)

4. Primary Agency Representative (this individual will be given voting rights at MiREMS membership meetings) (Required.)

5. Primary Representative Phone (Required.)

6. Primary Representative Email

7. Is the primary representative also the billing contact? (Required.)

8. Approximate number of agency employees (Required.)

9. Agency staffing model (Required.)

10. Requested membership level (Required.)

11. Payment preference (for invoicing purposes) (Required.)

12. Acknowledgement (Required.)

13. Is there anything additional you would like MiREMS to know about your agency?