Get Pa Cssmcw New Membership Application & Agreement – Davidsville 2019-2025

Filling out the PA CSSMCW New Membership Application & Agreement is essential for becoming a member of Davidsville HealthStyles. This guide provides clear instructions on how to complete the application accurately and efficiently while ensuring you meet all necessary requirements.

Follow the steps to complete your membership application online.

1. Click ‘Get Form’ button to obtain the application form and access it in your preferred editor.
2. Begin filling out the applicant name section, entering your last and first name in the provided fields.
3. Complete your home address by providing your street address, city, state, and zip code.
4. Enter your date of birth and age in the respective fields.
5. Select your sex by marking either 'M' for male or 'F' for female.
6. Fill in your employer’s name and your occupation in the designated areas.
7. Provide your home phone, cell phone, and email address to ensure proper contact details.
8. Complete the emergency contact section, including the contact's name, phone number, and relationship to you.
9. Fill out your health insurance information and ID number as required.
10. List your primary care physician's name and the physician's phone number, and record the date of your last physical.
11. Review the acceptance and approval section and acknowledge that you read and understood the Terms and Conditions of Membership.
12. Sign and date the application agreement to confirm your understanding and acceptance of the terms.
13. Move on to the health questionnaire section, checking any health concerns that apply to you.
14. Assess your fitness level by selecting one of the options provided.
15. If applicable, specify any prescribed medications and provide additional health information as prompted in the form.
16. Complete the physical activity readiness questionnaire accurately, providing explanations where necessary.
17. Sign the health questionnaire and include the signature of a parent or guardian if you are under the age of majority.
18. Proceed to the informed consent section, reading through the agreement carefully before signing.
19. Finally, review the payment plan options, select your preferred method of payment, and complete the necessary financial information.
20. After completing all sections, save your changes, and if required, download, print, or share the application form.

Complete your PA CSSMCW New Membership Application & Agreement online today!