Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | They had to pay by CC in Stripe manually bc the CC field is missing on the DC AND DF sign up form. 10/20/26 MT |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Marc Girolamo |
| Email hidden; Javascript is required. | |
| Phone | (440) 321-3545 |
| Date of Birth | 02/01/1995 |
| List Family Members | Jamie Meurell |
| Enter Office Code | 34757 |
| Address | 38276 Poplar Dr Willoughby, OH 44094 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 | 10/20/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/20/2027 |
| Membership ID Number | 1792505414 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 2 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
