Online Application


First Name/s (required)


ID/Passport No

Home Address

Postal Code

Postal Address

Postal Code

Contact Numbers

Emergency Contact

Your Email (required)

Other Members of household

Member 2:

Member 3:

Member 4:

Member 5:

Member 6:

Joining-fee: Please debit my account on receipt of this application. Includes membership in the sign-on month.

Monthly Membership Fees

Extra People (over and above the 6 included) @ R50 p/person p/month

Membership for Domestic workers who live off the property @ R66 p/person p/month


By submitting 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/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.

Banking Details

Account in the name of:

Bank Name

Account Number


Preferred debit date
1st of month
15th of month

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.
I/we understand that the once-off Joining Fee includes membership of CMR for the joining month, with the first debit thereafter being made on the chosen debit date in the following month.
I understand that if a debit order is returned for non-payment, a fee of R110,00 will be charged to cover CMR's bank and administrative fees.