Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member requested senior discount. 9/18/25 EK Paid with CC in Stripe bc CC field is down on SU form. Changed EM after renewal, sent manually. 10/20/26 MT |
| 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. | 1758219291 |
| Your Name | Betty Posey |
| Email hidden; Javascript is required. | |
| Phone | (440) 714-7349 |
| Date of Birth | 06/25/1945 |
| List Family Members | William |
| Enter Office Code | GM1008 |
| Address | 4831 Washington Ave Lorain, OH 44052 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 | 10/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/28/2027 |
| Membership ID Number | 1792509879 |
| 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. *** |
