MEMBERSHIP AGREEMENT

for TakeCare members

Form is valid as of today: April 27, 2024 ChST

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Membership enrollment is easy. Simply complete and submit the form below.

TakeCare Members...

The signer of this Membership Agreement has a paid for membership by TakeCare at UNIFIED, Inc. (“UNIFIED”) subject to the terms and conditions set forth herein.

MEMBER INFORMATION

Member’s Name *

Member’s Mailing Address *

Date of Birth *

Enter Date of Birth as MM/DD/YYYY (example: 04/23/1980)

Primary Phone *

Mobile Phone *

Driver’s License OR ID Number *

Email Address *

Confirm Email Address *

Emergency Contact Name *

Emergency Contact Number *

Employer *

Employer Primary Phone *

Employer Mobile Phone

How did you hear about UNIFIED? *

Referral Member Name

MEMBERSHIP DETAILS

TakeCare Covered Membership

Government of Guam Agency Name *
Member Identification Number (If available)
Member Name *
Parent/Guardian Name (if applicable)
Membership Type: Gov Guam TakeCare Subscription	Unlimited Month to Month Membership: Paid For By TakeCare as part of benefits package 2021- 2022, or until terminated by TakeCare.

CLICK HERE TO READ “TERMS OF MEMBERSHIP AGREEMENT/RULES & REGULATIONS

I AGREE TO THE TERMS OF MEMBERSHIP AGREEMENT/RULES & REGULATIONS*

ENTER YOUR INITIALS HERE *

*To be able to click the "SUBMIT ENROLLMENT FORM" button, you must agree to our TERMS OF MEMBERSHIP AGREEMENT/RULES & REGULATIONS and “ENTER YOUR INITIALS”. Both would be considered as “signing” the form.Regarding your privacy, by proceeding with this form your personal data would be saved, processed, and used by third-party systems and platforms used to make this page available in efforts to provide more streamlined online services possible. By proceeding, you are also agreeing and opting into receiving emails and other forms of communication from service providers.