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Family Medical Services Plan Registration Form



Plan Membership Number_________________


Membership type: Please circle the appropriate membership and fill out the names of the members.


One-Person Membership

Name: __________________


Two-Person membership

Name: __________________

Name: __________________


Family Membership

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 PLUS an additional amount of $35 each month for each additional dependent child.


Name of Adult #1: ___________________________________

Name of Adult #2: ___________________________________

Name of Dependent Child #1:  __________________________

Name of Dependent Child # 2: __________________________

Name of Dependent Child #3 : __________________________

Name of Additional Dependent Child:  ____________________

Name of Additional Dependent Child:   ____________________

Name of Additional Dependent Child:  ____________________



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.