Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member might be canceling future plan, renewed back in November but told him he'd still be within his 30 day guarantee if he cancels before the plan starts 2/14/19 EK Member requested we resend SU EM, Done. 11/3/23 EK |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | Yes |
| Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card. | 1755552678 |
| Your Name | cameron laufer |
| Email hidden; Javascript is required. | |
| Phone | (216) 224-8519 |
| Date of Birth | 11/02/1978 |
| List Family Members | jodi, cadence, holden, siena |
| Address | 281 balthazar cir avon lake, OH 44012 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX5776 |
| Total | $139.95 |
| Go Green | Paperless Option | not |
| Terms |  I have read the Terms and Conditions and wish to purchase the Discount Medical Plan. |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 09/22/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/22/2027 |
| Membership ID Number | 1790012197 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 9 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
