Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Paid manually by CC in Stripe. SU form was not showing CC field at all. 09/22/26 MT |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Shelly Covert |
| Phone | (607) 227-0078 |
| Date of Birth | 07/22/1974 |
| List Family Members | Ethan |
| Enter Office Code | DC1295 |
| Address | 1815 Trumansburg Rd Trumansburg, NY 14886 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 1790108324 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
