CLASSIC LIFEGUARD | Membership
Primary Member Name (First, MI, Last)
Date of Birth (Month, Day, Year)
Phone (###-###-####)
Mailing Address
City
State
Zip Code
Other Family Members: Household family names living with the Primary Member
Name (First, MI, Last)
Date of Birth (Month/Day/Year)
Are you and family members listed above currently covered by health insurance? Yes/No
Health Insurance Company
Group Policy #
Member ID#
Policy Holder Name
Policy Holder Date of Birth (Month/Day/Year)
Credit Card Number
Expiration Date
Security Code
Signature (Note: typing your name in the box will represent your signature)
