CI Member Data Form

Date Submitted
Cryonics Institute Membership Data

Secure Form to update your records with CI Headquarters
Please fill out the data below to the best of your ability.

IF YOU HAVE QUESTIONS, are missing forms listed or have other issues, please continue with the information you do have now and include your question(s) in the appropriate section. Each section has a space to submit questions. We will contact you to provide any neccessary answers, guidance and forms.

Remember, something as simple as a wrong phone number can mean the difference between life or death, so even an incomplete form is helpful and useful if it provides us with up-to-date information.
Read and Understand the instructions.*

Yes, I have
I. Personal Information:
Full Name*

PrefixFirst NameMiddle NameLast NameTitle
Gender*

MaleFemale
Birthdate*

MonthDayYear
Occupation
II. Contact Information
Mailing Address

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Country
Residence Address Same as Mailing Address

Yes
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Pager

Area CodePhone Number
FAX

Area CodePhone Number
Primary E-mail
Secondary E-mail
Additional Information or Questions
III. EMERGENCY CONTACT INFORMATION

Your emergency contact should be a trusted friend or family member who is aware of and agrees with your cryonics arrangements. This person will need to be available to communicate with CI in the event of a cryonics emergency.
Emergency Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
IIIa: SPOUSE / PARTNER STATUS

Your Spouse or Partner is often your best emergency contact person. Even if he or she is NOT your designated emergency contact, it is important this person is included in your file as they will likely be present and involved during an emergency situation.
Spouse or Partner Name

First NameLast Name
Phone Number

Area CodePhone Number
Married / Partner Status:

HusbandWifePartnerNone
Spouse / Partner Agreement:

YESNOI need information on this question.
Spouse / Partner Consent:

YESNOI need information on this question.
IIIb: NEXT OF KIN
Next of Kin Name

First NameLast Name
Relation of Next of Kin
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Next of Kin Agreement

YesNoI need information on this question
Additional Information or Questions
IV: CI CONTRACTS AND FORMS
Please complete this section to the best of your ability and indicate if you are either missing or have a question about a particular form or contract. CI staff will be happy to contact you in order to provide you with the neccessary information, forms and instructions required.

* IMPORTANT: Remember, a majority of problem cryonics cases arise from incomplete or incorrect paperwork. Please be sure to review all items in this list and indicate those you need help with. Our goal is to provide you with every opportunity for a successful cryonic suspension.
Cryopreservation Membership

YES (signed application)NOPlease contact me
Suspension Agreement

YES (signed contract in place)NOPlease contact me
Local Help Rider

YESNOPlease contact me
Non-Suspension Rider (Rider A Version 1 or 2)

YESNOPlease contact me
Option Two Rider (Yearly Membership Rider)

YESNOPlease contact me
Last Will and Testament

YESNOPlease contact me
Uniform Donor Form

YESNOPlease contact me
Objection to Autopsy Form

YESNOPlease contact me
Questionnaire / Personal History Form

YESNOPlease contact me
Standby Contract with Suspended Animation Inc.

YESNOPlease contact me
Additional Information or Questions
V: CI MEMBERSHIP AND FUNDING
* IMPORTANT: Please be sure to carefully review all items in this list and indicate any you need help with. Unfunded or lapsed funding arrangements can critically affect your cryopreservation!

Please complete this section to the best of your ability and indicate if you are either missing or have a question about a particular form or contract. CI staff will be happy to contact you in order to provide you with the neccessary information, forms and instructions required.
Cryonics Institute Membership

ANNUALLIFETIMENot sure
ANNUAL DUES PAID THROUGH:

MonthDayYear
Date
* If you are an annual (paid yearly) member, you could save a significant amount of money over the course of your membership by switching to lifetime. A Lifetime Membership also avoids the issue of a lapsed membership in the event of a cryonics emergency.
Suspension Agreement Funding

YESNOPlease contact me
Suspension Agreement Funding Amount
Suspension Agreement Funding Method
LIFE INSURANCE POLICY, PRE-PAID, OTHER
Annual Proof of Funding Submitted

YESNOPlease contact me
Proof of funding is required annually. Please set a date to provide this information to CI every year. Usually, this is when your Life Insurance Policy is paid and renewed.

Contracts that have been Pre-Paid (in full) do not require proof of funding validation.
Additional information or questions
VI: ADDITIONAL SERVICES
DNA Tissue Storage

YESNO
Pet Suspension / Storage

YESNO
Cryonics (or related) preservation services with another company?

YESNO
Company (if YES to question above)
VII. Comments
Please include any additional comments, information or questions here for CI Staff. Your answers and comments in the previous sections will help us to identify the areas you need help with. If you would like to schedule time to speak with CI staff, please don't hesitate to contact us.
Additional Comments

0/500
THANK YOU FOR YOUR HELP!
Thank you again for helping us help you acheive an optimal cryonic suspension by providing us with your most up-to-date information.

Please bookmark this form, and in the future if you have any changes you may re-submit this form answering however few or many questions you need to in order to update your information. (i.e. a new phone number, updated contract status, marriage status, or etc.)
Should be Empty:

Cryonics Institute Membership Data

I. Personal Information:

II. Contact Information

III. EMERGENCY CONTACT INFORMATION

IV: CI CONTRACTS AND FORMS

V: CI MEMBERSHIP AND FUNDING

VI: ADDITIONAL SERVICES

VII. Comments

THANK YOU FOR YOUR HELP!