Program Change Form: Evergreen Version

Membership Account Information

Please enter your current Membership account information below.
Member ID*
Input your current Member ID above
Primary Email on Membership*

Confirmation EmailPlease use the email address associated with your Member Care Portal login.
Primary Member Name*

First NameLast NameSuffix
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Do you need to update any of your contact information?

Contact Information Updates

Please use the fields below to update the contact information for your Solidarity Membership.
Updated Address

Street Address

Street Address Line 2

CityState

Zip Code
Updated Phone Number
Please enter a valid phone number.
Updated Email on Membership

Confirmation Email*NOTE: Updating your Membership email will change the login email for the Member Care Portal*

Program Effective Date

Please provide your desired Effective Date.
Important Reminder: All program change requests require that notification is received by the first (1st) day of the month prior to the month in which the Member intends the program change to take effect. Program changes cannot be applied to a retroactive date.
Desired Effective Date (must be 1st of month)*

MonthDayYear

Current Program Information

Please provide the following information on your current Membership.
Please select your current active household size below:*

Single (1 Member)Couple (2 Members)Family (3+ Members)
Current Program Information

Please provide the following information on your current Membership.
How old will the oldest active Member on your Single Membership be as of your desired Effective Date?*
Please select the appropriate age range from the list above.
How old will the oldest active Member on your Couple (2 Members) Membership be as of your desired Effective Date?*
Please select the appropriate age range from the list above.
How old will the oldest active Member on your Family (3+ Members) Membership be as of your desired Effective Date?*
Please select the appropriate age range from the list above.

Review Your Program Change

A summary of your Membership information and new program selection can be reviewed below. To make any changes to the information, click the back button at the bottom of the screen.
Membership ID: {MemberID}

Current Membership Information:

Primary Member Name: {PrimaryMemberName}

Email on Membership: {PrimaryEmail}

Address: {CurrentAddress}

Phone: {phoneNumber}

Updated Contact Information (if added)

Updated Address: {updatedAddress}

Updated Phone Number: {updatedPhoneNumber}

New Email for Membership: {updatedEmailAddress}

*NOTE: Updating your Membership Email will change the login email for the Member Care Portal*

Your New Program Selection

You have selected a {HouseholdSize} program where the oldest active Member is {ageOldestSingle}{ageOldestCouple}{ageOldestFamily} years old as of {desiredEffectiveDate}.

Your new program selection is {programSingle0to24}{programCouple0to24}{programFamily0to24}{programSingle25to34}{programCouple25to34}{programFamily25to34}{programSingle35to44}{programCouple35to44}{programFamily35to44}{programSingle45to54}{programCouple45to54}{programFamily45to54}{programSingle55to64}{programCouple55to64}{programFamily55to64}{programSingle65andOver}{programCouple65andOver}{programFamily65andOver}, and your desired Effective Date is {desiredEffectiveDate}.

Program Change Agreement

Please review and accept the statements below regarding your program change.
1. I have recorded my Membership information accurately to the best of my knowledge.
2. I reviewed my program change request and accept the change.
3. I understand that if I selected a Solidarity ONE program my Annual Unshared Amount will reset to $0.00 on my new Effective Date.
4. I understand and accept my new Monthly Contribution amount.
5. I understand that I can only make one (1) Membership Program change during my current Membership year.
6. I understand that I cannot change my Membership Program from a higher Annual Unshared Amount to a lower Annual Unshared Amount during my current Membership year.
Text Messaging Opt-In:

I would like to receive updates and announcements regarding my Membership via SMS messages. Data rates may apply. Opt-out anytime.
Mobile Number*
Please enter a valid phone number where we can provide you with text message updates.
By checking the box below and submitting this form, I agree to the above statements.*

I agree to the Program Change Agreement
Signature*
Please verify that you are human.*
Hidden "From" field for email notifications.*
Should be Empty:

Program Change Form