Household Application


First Name/s (required)



Home Address


Postal Address


Contact Numbers

Local emergency contact

Your Email (required)

Other Members of household

Member 2:

Member 3:

Member 4:

Member 5:

Member 6:

Once-off joining-fee: The joining fee includes membership in the sign-on month and is payable at commencement of membership.

I wish to pay the joining-fee by:

Monthly Membership Fees

Hospital Transportation Cover

Extra Person (over and above the 6 included) @ R40 p/person p/month

Membership for Domestic workers who live off the property @ R55 p/person p/month

Extra B&B beds. Paramedic Service only @ R27,50 p/bed p/month

Banking Details

Account Name

Bank Name

Account Number

Branch Name

Branch Code


Preferred debit date

Account contact person (if different to main member)

Contact Number (if different to main member's)

Email (if different to main member's)

I/we hereby authorize Cape Medical Response C.C. to debit my/our account with the monthly premium starting in the month following signature date below. I/we understand that the once-off Joining-Month Fee includes membership of CMR for the joining month, with the first debit being made on the chosen debit date in the following month or month thereafter.
I agree

By submitting this form:

I/we authorize Cape Medical Response CC to debit my/our account with the monthly premium indicated above starting in the month following submission of this form.
I/we understand that CMR Membership only becomes valid when approved by CMR, and when the Joining Month Fee is received by CMR.
I understand that if a debit order is returned for non-payment, a fee of R90,00 will be charged to cover CMR's bank and administrative fees.
I/we agree to subscribe to the service for two years in accordance with CMR's Standard Terms & Conditions.
I/we confirm that I/we have read and understood the terms and conditions that apply to my relationship with CMR, and agree to the terms thereof. (View CMR's Standard Terms & Conditions here)