ROCKET Connect - Application form

Dear User

ROCKET Connect has launched a new and improved Panic App, making it easier for you to manage your membership and access your emergency medical benefits.

With the new app, you can:

- Make your membership payment directly during the sign-up process.
- Add or remove members at any time.
- View your payment history.
- Access your incident history.

To register for the new ROCKET Connect emergency solution, simply complete the details below and click Submit. You will then be directed to the sign-up link for the new Panic App.

Thank you for choosing ROCKET Connect.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

NUMBER OF MEMBERS - INCLUDING MAIN MEMBER

R75.00 PER MEMBER / PER MONTH

Please select your ambassador

Please select the ambassador that reffered you to ROCKET Connect

Province