SeniorChoice Membership Renewal

CRMC SeniorChoice strives to provide services that support the emotional, social and physical wellbeing of those of our community who are 50 or better.

As a member of CRMC SeniorChoice you will receive several great benefits.

Annual membership fee:

$25 per person
$45 per couple

CRMC SeniorChoice is not an insurance program.

Please fill out the form below. You may pay your membership fee by credit card or by check. All information will be kept secure and confidential. For more information you may call our office during business hours at 256-737-2600.

First Name*
Last Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Membership for:*
- One Person - $25
- Couple - $45
Spouse's Name*
Spouse's Date of Birth
MM slash DD slash YYYY
Spouse's Gender
- Male
- Female
Credit Card*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Comments Related To Your Payment