Family Application Form

Emergency Medical Rescue Membership Package Application Form

Personal Details

Client Type
Principal member name
National ID/ Passport/Drivers' Licence
DD slash MM slash YYYY
Address

Principal member medical history

Have you ever suffered from a heart condition?
Have you ever been in hospital in the last year?
Have you ever been diagnosed with:
Indicate any allergies and pre-existing conditions you might have. Type Non if nothing
Please share any relevant medical history details we would need to know before assisting you in an emergency.

Dependants Details

Upload dependant details in an Excel file showing names, ID number, age, gender, medical history and allergies.
Max. file size: 1 GB.

Dependant 1 details

Dependant 1 name

Dependant 2 details

Dependant 2 name

Dependant 3 details

Dependant 3 name

Dependant 4 details

Dependant 4 name

Select service and duration

Service Type
Select subscription duration. Minimum 6 months. 1 to 5 are for Zambezi Cover - Tourist
Payment Method