Mandatory fields are denoted by *

 

* Title
* First Names
* Surname / Last Name
* Gender Male Female
* Date of Birth    
Month-DD-CCYY
* 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

Have you been a member of a medical scheme registered in South Africa for at least 24 months and less than 90 days have passed since your resignation from that Scheme?

 Yes  No

 

Please provide certificates of membership for previous schemes.

* Name of Scheme * Membership Number * Date joined yy/mm/dd * Date terminated yy/mm/dd or current