Test form Signups
| Status | Active |
|---|---|
| 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. | 1725545816 |
| Your Name | Lisa Harper |
| Email hidden; Javascript is required. | |
| Phone | (570) 205-1351 |
| Date of Birth | 02/19/1976 |
| List Family Members | Ashley, Katey |
| Referred by or Referral Code | Debra Vivaqua nonmember Done |
| Enter Office Code | A12522 |
| Address | 478 W Frack Street Frackville, PA 17931 Map It |
| Payment Method | PayPal |
| 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 | 09/23/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/23/2027 |
| Membership ID Number | 1790178533 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
| Payment Method | PayPal Checkout |
