Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | How do they want to pay? Called member and got payment by cc over the phone 9/24/26 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. | 1756144687 |
| Your Name | Shelly Muscarello |
| Email hidden; Javascript is required. | |
| Phone | (504) 554-0622 |
| Date of Birth | 09/27/1965 |
| List Family Members | Chris Muscarello |
| Enter Office Code | RG2142 |
| Address | 5072 Dueling Oaks Ave Marrero, LA 70072 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 | 09/26/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/26/2027 |
| Membership ID Number | 1790280283 |
| 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. *** |
