City of Henderson Fire Department
LifeRide Plan Registration
Please complete the form below to create your account.
Address Information (Required)
Address 1
Address 2
City
State
Zip Code
Primary Member Information (Required)
First Name
Last Name
Date of Birth
Must be 18 years or older
Primary Phone
(
)
-
Alt. Phone
(
)
-
Insurance Information (Optional)
Insurance Provider
ID#
Group#
Mailing Address Information (Required)
Same as Address
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip Code
Online Account Information (Required)
Email Address
(used as account login)
Confirm Email Address
Password
(Min. of 9 characters, 1 uppercase and lowercase, 1 special character and not a common password)
Confirm Password
I ,
, agree to the
terms and conditions
of the LifeRide Program.
Required
Cancel