CMR MyLifeLine Panic Button Application

Complete the form below to apply for your CMR MyLifeLine Panic Button. An active CMR membership is required.

1. Member Information

Full Name of Primary CMR Member *

CMR Membership Number *

Physical Address *

2. MyLifeLine Device Details

Full Name of Device Holder *

Cellphone Number for Low Battery Notifications *

Preferred Payment Method *
Select Payment MethodCashEFTCard

3. Emergency SMS Contacts

When your MyLifeLine Panic Button is activated, SMS notifications will be sent to your nominated contacts. Please select people who live nearby or are familiar with your daily movements.

Emergency Contact 1: Full Name *

Emergency Contact 1: Cellphone Number *

Emergency Contact 2: Full Name *

Emergency Contact 2: Cellphone Number *

4. Pricing

Once-off Device Purchase: R2,500 incl. VAT

Monthly Network Provider Fee: R55 incl. VAT

The monthly network provider fee will be added to your existing CMR membership fee.

5. Terms & Conditions

By submitting this application, I/we acknowledge and understand that:

• CMR's Standard Terms & Conditions apply to all services.

• The service may be cancelled with one month's reciprocal written notice.

• Rates increase annually on 1 April.

• CMR acts as an agent for MyLifeLine devices. Product faults and technical problems are referred to MyLifeLine.

• MyLifeLine's Terms of Service apply to the device.

• CMR shall not be liable for losses or damages resulting from product faults or problems, including the receipt or non-receipt of signals from the device.

• Ownership of the device transfers to the purchaser upon delivery.

• The device holder is responsible for keeping the device sufficiently charged.

• Low-battery notifications are sent only to the cellphone number provided.

• An active CMR membership is required for CMR to provide services or receive signals from the device.

• If the device remains uncharged for approximately two months, its SIM card may expire. Replacement SIM card costs will be for the member's account.

I confirm that I have read and understood the MyLifeLine Panic Button Terms & Conditions and CMR's Standard Terms & Conditions, and agree to be bound by them.

I acknowledge the once-off purchase price of R2,500 including VAT and authorise Cape Medical Response to add the R55 including VAT monthly network provider fee to my existing CMR membership debit order.