Crunch Membership Request

Crunch Membership Request Form

Please Note: This DOES NOT give you membership to Crunch. This form is sent to Crunch to verify eligibility and complete the membership process. Do not submit this form more than once. If you have already completed a submission, do not submit a duplicate. Contact benefits@mymanatee.org if you need to make a correction or have questions.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
E-mail*
Cell Number*
Are you a member of the YourChoice Health Plan?*

YesNo
Only members on the YourChoice Health Plan are eligible for this Crunch Membership.
Are you a current member of Crunch?*

YesNo
ATTENTION CURRENT CRUNCH MEMBERS:
Any current Crunch member must GO IN to their local Crunch front desk to CANCEL their current membership and ensure December is their last billing period. YourChoice is a new membership and memberships CANNOT be transferred.
Should be Empty:

Crunch Membership Request Form