Mandatory fields are denoted by *


* Title
* First Names
* Surname / Last Name
* Gender Male Female
* Date of Birth     For applicants under the age of 18: Please attach a confirmatory letter from the intended guardian
* ID Number                 Number must be completed
 Student Number
* Email
* Marital Status
*Institution     Please note: If you do not select the right institution, you will not receive your membership card

* Question 1

Have you been accepted, or are you planning to study full time, at an institution in South Africa ?

Yes No

* Question 2

Have you currently enrolled as a full time student at a South African Institution ?

Yes No

* Question 3

Are you an active member on a medical scheme?

 Yes  No
* Name of Scheme
* Member Number
* Start date DD/MM/CCYY
* End date DD/MM/CCYY