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
Format: (000) 000-0000.
Are you a member of the YourChoice Health Plan?
Only members on the YourChoice Health Plan are eligible for this Crunch Membership.
Are you a current member of Crunch?
ATTENTION CURRENT CRUNCH MEMBERS:
Any current Crunch member must GO IN to their local Crunch front desk to CANCEL their current membership. YourChoice is a new membership and memberships CANNOT be transferred.
Should be Empty:

Crunch Membership Request Form