Select

Section A is Required. Ignore Section B if person responsible for payment is not the main member..

  • Membership Type
  • Main Member Details
  • Dependent Details
  • Payment Details

Select Membership Type

Select Membership Type

Number of Adult Dependents

Ages of Adult Dependents (Separated by commas)

Number of Minor Dependents

Ages of Minor Dependents

Select Plan

Main Member details

Surname

First Name (s)

Title

ID Number

Gender

Date of Birth

Marital Status

Main Member Mobile Number

Main Member Email Address

Main Member Home Address

Main Member Next of Kin Details

Next of Kin Name

Next of Kin Relationship

Next of Kin Address

Next of Kin Mobile Number

1st Dependent

First Name’s

Surname

Gender

Relationship to Member

Date of Birth

ID Number

2nd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

3rd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

4th Dependent

First Name(s)

Surnames

Date of Birth

Gender

Relationship to Member

ID Number

Person or Entity Responsible for Payment

Is the Person Responsible for Payment the Main Member?

Payment Frequency

Preferred Payment Method

Section B Sponsor Details

Name of Sponsor

Residential Address of Sponsor

Bussiness Address (Only Fill if Applicable)

Mobile Mobile Number

Business Phone Number

Email Adresss

  • Main Member Details
  • Payment Details
  • Dependent Details
  • Membership Type

Main Member details

Surname

First Name (s)

Title

ID Number

Gender

Date of Birth

Marital Status

step1

1st Dependent

First Name’s

Surname

Gender

Relationship to Member

Date of Birth

ID Number

2nd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

3rd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

4th Dependent

First Name(s)

Surnames

Date of Birth

Gender

Relationship to Member

ID Number

Select Membership Type

  • Main Member Details
  • Payment Details
  • Dependent Details
  • Membership Type

Main Member details

Surname

First Name (s)

Title

ID Number

Gender

Date of Birth

Marital Status

step1

1st Dependent

First Name’s

Surname

Gender

Relationship to Member

Date of Birth

ID Number

2nd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

3rd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

4th Dependent

First Name(s)

Surnames

Date of Birth

Gender

Relationship to Member

ID Number

Select Membership Type

  • Main Member Details
  • Payment Details
  • Dependent Details
  • Membership Type

Main Member details

Surname

First Name (s)

Title

ID Number

Gender

Date of Birth

Marital Status

step1

1st Dependent

First Name’s

Surname

Gender

Relationship to Member

Date of Birth

ID Number

2nd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

3rd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

4th Dependent

First Name(s)

Surnames

Date of Birth

Gender

Relationship to Member

ID Number

Select Membership Type

  • Main Member Details
  • Payment Details
  • Dependent Details
  • Membership Type
  • Addons

Main Member details

Surname

First Name (s)

Title

ID Number

Gender

Date of Birth

Marital Status

Upload Passport Size Picture

step1

1st Dependent

First Name’s

Surname

Gender

Relationship to Member

Date of Birth

ID Number

Passport Size Picture

2nd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

Passport Size Picture

3rd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

Passport Size Picture

4th Dependent

First Name(s)

Surnames

Date of Birth

Gender

Relationship to Member

ID Number

Passport Size Picture

Select Membership Type

Select Plan Addons

  • Main Member Details
  • Payment Details
  • Dependent Details
  • Membership Type
  • Addons

Main Member details

Surname

First Name (s)

Title

ID Number

Gender

Date of Birth

Marital Status

Upload Passport Size Picture

step1

1st Dependent

First Name’s

Surname

Gender

Relationship to Member

Date of Birth

ID Number

Passport Size Picture

2nd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

Passport Size Picture

3rd Dependent

First Name(s)

Surname

Date of Birth

Gender

Relationship to Member

ID Number

Passport Size Picture

4th Dependent

First Name(s)

Surnames

Date of Birth

Gender

Relationship to Member

ID Number

Passport Size Picture

Select Membership Type

Select Plan Addons