5 Year Membership Plan
18 Guaranteed Member Services

Regular Rate = Family $3,495 or Individual $2,395
Club Rate Family $ 2,495 Individual $ 1,995
The SkyMed ULTIMATE membership plan provides 18 essential
member services at home or while traveling!
INCLUDES GLOBAL
Enjoy the very best in emergency air-transport service with ALL
of the SkyMed options for 5 full years at a discounted rate.
3 Year Membership Plan
17 Guaranteed Member Services

Regular Rate = Family $2,095 or Individual $1,695
Club Rate Family $ 1,695 Individual $ 1,295
The SkyMed ULTIMATE membership plan provides 17
essential member services at home or while traveling!
DOES NOT INCLUDES GLOBAL
Enjoy the very best in emergency air-transport service with ALL
of the SkyMed options for 3 full years at a discounted rate.
Do you live or travel to another country other than your own for more than 6 months in 12 consecutive months? Yes No
Last Name: First Name: Date of Birth:
Medical conditions/Medications
Companion Last Name: Companion First Name: Date of Birth:
Medical conditions/Medications
Home Address: City: State: Zip: Country:
Transport City:
(Subject to approval if transport location is different than the home)
State: Zip: Country:
Temporary mailing address for packet if different from above City: State: Zip: Country:
Phone: Cell: Email:
Credit Card #: EXP (MM/YR): Amount Paid:
Referring RV Club:
APPLICATION INFORMATION: To Become Eligible and Qualify, all medical conditions and prescribed medications must be listed. Pre-existing medical conditions are covered after 90 days on members that qualify. Any person who knowingly and with intent to injure, defraud, or deceive SkyMed by submitting a statement of service or an application containing false, incomplete, or misleading information may be guilty of a third degree felony. By signing this application, you are giving SkyMed permission to contact your doctor to obtain medical records.
Applicant Signature: Date:
 
 
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