Since 2004, Global Rescue has been the world’s leading provider of medical, security, evacuation and travel risk management services to enterprises, governments and individuals.

Extended Memberships are for travelers 75 to 85 years of age. For individuals over age 85, medical transport benefits are available on a fee-for-service basis. Please complete this application if you are or will be 75 years of age or older when traveling. If insufficient space, attach additional pages to the form when submitting, i.e. problem list, medication list, etc. After payment is received, your membership becomes effective on the date indicated during sign up. You will receive an email when your account has been activated. Applications cannot be submitted more than 90 days prior to the membership start date.

For more information regarding Global Rescue membership services, visit www.globalrescue.com, or call (617) 459-4200.

INSTRUCTIONS :

1. Indicate your desired membership in the Extended Travel Services Membership Plans and Pricing section. Please choose only one.

2. Complete the General Information and Payment Information sections in full and indicate you agree to the Member Services Agreement and Terms of Service.

3. Answer all six questions in the Medical History and Information section completely and in detail to the best of your ability, including dates of diagnosis and treatment.

   • If a question does not apply to you write “N/A” on the line.

   • Please attach additional pages to this application if the lines provided do not give enough space for all information.

   • Medications list must include the reason for taking.

4. Complete the Personal Information section completely.

5. Sign both pages of the application.

6. Submit your application.

IMPORTANT NOTE:

If the Member omits relevant medical information, is hospitalized due to circumstances diagnosed or treated within one year prior to this application, or for which symptoms existed which would cause a prudent person to seek such diagnosis or treatment, travel benefits may be excluded or denied. Acceptance of this form does not constitute a guarantee of services.

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PERSONAL INFORMATION

Email

Gender
MaleFemale

DOB *

phone

Address

City

City

State
Select State

Country
Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe

PAYMENT INFORMATION

Credit Card Number

Exp Date

CVV

(*The three- or four-digit security code on the front or back of the card)

Billing Address

State

Zip

Signature

How did you hear about us?

RP Code

YES I have read and agree to the Member Services Agreement on the Global Rescue website. Date:
The Membership Services Agreement can be found at http://www.globalrescue.com/agreement.cfm
You will receive an email when your account has been activated. Global Rescue encourages you to log into your account and fill in critical information, such as emergency contacts, health history, etc.
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MEDICAL HISTORY AND INFORMATION

Please explain any above medical conditions to include diagnosis and treatment dates

Please list any medical conditions not listed above, and include diagnosis and treatment dates

Please list any hospitalizations, surgeries or procedures you have undergone in the last 5 years with dates

Please list any medications you currently take and indicate what you take them for

GENERAL INFORMATION

Trip dates and location

Expected activity during travel

Primary Care Provider

Address

Phone Number

Do you have a disability?
YESNO

If yes, please explain

We may need to contact your primary care provider before approving your application. Do you consent to Global Rescue and physicians at
Elite Medical Group contacting the above-named provider for this purpose? If so, please sign the statement below

I authorize Global Rescue, LLC, to contact my provider and I further authorize my provider and her/
his staff to share my medical history and current health information with Global Rescue, LLC.

Signature

Date

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