Student/Family Lifeline™ Application
FREE MEMBERSHIP APPLICATION INTO LIFELINE

STUDENT LIFELINE PO BOX 97, 922 Hempstead TPKE. Franklin Square, N.Y. 11010
1-800-543-3829

Police, School, organization sponsor distribution programs are accomplished at no cost to recipients
via advertising funds.
No annual membership fees are required under these programs
Free shipment of cards paid for by local advertising.

Please submit the form below or print this form and fill it out.
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The following student/family member hereby enrolls into an annual membership of either the Student™ or Gold™ Lifeline Card Service. UNDERSIGNED is hereby entitled to unlimited emergency rides, up to $100.00 per incident, 24/7, under the following conditions:

  1. Teen avoiding a drunk driver / threatening date.

  2. Any aged member brought to home address whenever involved in a vehicle breakdown / accident.

  3. Whenever member is a victim of a crime.

  4. Abused adult or child to shelter.

Adult (Gold)      Student (under 21 years old)


 Name of Proposed Member



 Address


 ( A/C ) Telephone Number


 ( A/C ) Fax Number


 Social Security Number


 Email


 

Free applications to individuals and organizations.
 


 


 

 

If proposed member is under 18 years old, a parent/guardian hereby attests to authorizing in having minor receive Student Lifeline membership:
Parent/Guardian

Signature of Member


Allow 2 weeks to receive member card and materials.