AmeriCorps Full-Time Member Health Care and Child Care Enrollment/Waiver Form Please Sign and Return Health Care: ____ Enroll me in the program’s health care plan. ____ enroll plan, as I have other health Do not me in the program’s health care coverage. ____ enroll health care plan, even though I have Do not do not me in the program’s other health coverage. Child Care: ____ I am interested in pursuing enrollment in the AmeriCorps*State child care benefit. ____ I am interested in the AmeriCorps*State child care benefit. not Member Name __________________________________________ (please print): Member Signature: ________________________________________________ Date: ___________________________________________________________ Required to check one option under each section.
AmeriCorps Full-Time Member Health Care and Child Care Enrollment/Waiver Form Please Sign and Return Health Care: ____ Enroll me in the program’s health care plan. ____ Do not enroll me in the program’s health care plan, as I have other health coverage. ____ Do not enroll me in the program’s health care plan, even though I do not have other health coverage. Child Care: ____ I am interested in pursuing enrollment in the AmeriCorps*State child care benefit. ____ I am not interested in the AmeriCorps*State child care benefit. Member Name (please print): __________________________________________ Member Signature: ________________________________________________ Date: ___________________________________________________________ Required to check one option under each section.
Health_and_Child_Care_Benefit_Form_-_Member.docx