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. | 1753211461 |
| Your Name | Rebecca Russ |
| Email hidden; Javascript is required. | |
| Phone | (717) 816-5947 |
| Date of Birth | 05/11/1956 |
| List Family Members | Teddy |
| Referred by or Referral Code | ExMail 07/22/2025 |
| Enter Office Code | DC1101 |
| Address | PO Box 4 James Creek, PA 16657 Map It |
| Payment Method | Credit Card |
| Credit Card | amex XXXXXXXXXXXX1018 |
| Total | $139.95 |
| Go Green | Paperless Option | yes |
| 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 | 10/02/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/02/2027 |
| Membership ID Number | 1790870517 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
