Family Medical Services Plan Registration Form
Plan Membership Number_________________
Membership type: Please circle the appropriate membership and fill out the names of the members.
Please note that in order to qualify for a
family membership for a fee of $15 a month, there must be no greater than
five (5) members in the family: a maximum of two (2) adults and three (3)
dependent children. If you wish to include more than three (3) dependent
children within the Family Membership, you must pay $150 a month
Name of Adult #1:
I acknowledge that I have read the terms and conditions of the Family Medical Services Plan and agree to be bound by them on behalf of myself and each other member listed above.