Application for Membership

Applicant Information

*Indicates a Required Field
First Name*
Last Name*
Middle Init
Gender*
SSN #
Date of Birth
(mm/dd/yyyy)
Address*
Address2
City*
State*
 
Zip*
Primary Phone*
Work Phone
Cell Phone
Email*
 
Confirm Email*
Participation Level
Add Brother's Keeper: Membership increases your maximum sharing amount. Click here to learn more.
 
Qualify for Medicare
Medicare A and B

Spouse Information (if applicable)

First Name
Last Name
Middle Init
SSN #
Date of Birth
(mm/dd/yyyy)
Participation Level
Add Brother's Keeper
Qualify for Medicare
Medicare A and B

Dependent Information (if applicable)

 
First Name*
Last Name*
Date of Birth*
(mm/dd/yyyy)
Gender*
Join Now
SSN
If 18 years or older, please select all that apply:
 
             My adult child is 25 years old or younger.
   My adult child is a Christian living by biblical principles.
 
             My adult child is not married.
   My adult child is reported as a dependent on my income tax forms.
 
 
Participation Level for all dependents
Add Brother's Keeper
 
       

Previous Condition Information (if applicable)

Please include information about all conditions for which you have experienced signs, symptoms, or treatment within the past five years. Your membership in Christian Healthcare Ministries will not be denied based on the information you provide. The information will, however, help us determine if we can assist you through one of our programs for pre-existing conditions.
 
 

Sponsor Information (if applicable)

    Learn more about our Bring-a-Friend referral program
Member Name
Member Number**
Sponsor Group
**If you don't know the Member Number, please use the comments field at the end of this application to submit more information about the sponsoring membership.

Payment Information

Monthly Gift Amount
Brother's Keeper Annual Fee
           There is a $40 annual fee per family. An additional quarterly fee applies. Click here for information.
 
 
Total this transaction
Start Date
(mm/dd/yyyy)
Promotion Code (if applicable)
Group Name (if applicable)
Payment Method

Forward Information About Christian Healthcare Ministries to Your Friends

(You can earn a free month of participation for each one who joins the ministry.)
 
 
Full Name
Address
City
State
 
Zip
Phone
Email
 
 

How did you hear about us?

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Additional Comments

You have 230 characters remaining
    By clicking the submit button below, I am submitting this application to become an active member of CHM and attest that the participating adult members included herein are Christians living by biblical principles; attend group worship regularly (health permitting); follow scriptural teaching with regard to alcohol; and do not use tobacco or use drugs illegally. I also attest that all information provided herein is true to the best of my knowledge.
 
    I also understand that it's my responsibility to read the CHM Guidelines and that any medical bills I or my family members submit for sharing will be authorized according to the Guidelines.