Membership Form Share Title Initials GenderMaleFemalePrefer Not To SayDate MM slash DD slash YYYY Name First Last ID Number Occupation PhoneEmail Physical Address (Where someone can sign receipt of your membership package) Street Address City State / Province / Region ZIP / Postal Code Diabetic Type Type 1 Type 2 Pre Diabetic Family Member/Non Diabetic Current Medication State Patient At Name Of Medical AID Cell PhoneEmergency Contact (To print on your membership card)Next of Kin Name Next of Kin Phone Number Please send me a free Blood glucose meter Yes No I would like to receive info newsletters regularly Yes No I would like to speak to a medxpert consultant about my medical aid benefits Yes No Diabetes S.A. MembershipPLEASE NOTE: ANNUAL MEMBERSHIP FEES ARE DUE ONCE EVERY YEAR TO RETAIN MEMBERSHIP. YOUR MEMBERSHIP STARTS ON THE DAY YOU PAY, YOUR RENEWAL WILL BE DUE ON THE SAME DATE THE FOLLOWING YEAR. ALTERNATIVELY YOU CAN CHOOSE A MONTHLY DEBIT ORDER PAYMENT. Diabetes S.A. will send you a debit order form to complete should you choose this option.PLATINUM:MEMBERSHIP Per Annum R320 Monthly Debit Order R35 GOLD:MEMBERSHIP Per Annum R150 Monthly Debit Oder R20 ADDITIONAL DONATION Quantity(scroll your donation amount) Price: R10.00 Quantity Total
