Family Membership

1. Personal Information

Email Address

Phone Number

Gender:

Male Female

Birth Date Applicants must be over 18 and under 64

Height

Weight (lbs)

2. Account Security

Create Password (Min 8 characters, at least 1 number, 1 symbol, 1 uppercase, 1 lowercase)

Confirm Password

3. Household Information

Who are you signing up for?

Myself Myself & My Family

How many additional family members? 0 1 2 3 4

4. Address

Street Address

Apt/Suite Number

City

State Select State Alabama Alaska

Zip Code

Country Select Country United States Canada

My mailing address is different

5. Health Background

Do you currently have health coverage?

No, I have no coverage Yes, through employer Yes, individual plan Yes, COBRA or short-term Other

Have you smoked or used tobacco products daily for 1 year or more?

Yes No

In the last 5 years, have you had any pre-existing symptoms or medical conditions?

Yes No

If yes, explain briefly:

6. Occupation

What type of work do you do?

Real Estate Dental Care Business Owner Fitness Startup Contractor Doctor/Nurse Freelancer Student Other

7. Membership Details

How did you hear about us?

When would you like to start using CrowdHealth? (Anytime within the next 6 months)

Promo or Referral Code

Auto-renews and cancel anytime