Newborn Enrollment Form

  • Newborn Enrollment Form

    Please fill out the information below. Once we have received this information, we will be able to add your newborn to your Membership.

  • According to our Sharing Guidelines, "A newborn child of a Member may be added to a membership as a Dependent Child. The Member should notify Solidarity HealthShare in writing within thirty (30) days of the birth of the child." We are able to add a newborn to an existing Membership as of the date of their birth, as long as we receive the newborn's information within 30 days of their date of birth. 

    If you are submitting this form more than 30 days after the date of birth for your newborn, they will be added to your Membership as of the first of the next available month. Please instead fill out our Add a Member Form.

  • Membership Information


  • Newborn Information

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  • Review Your Newborn Enrollment Information Submission

  • Please review the information you entered before submitting your form

     

    Primary Member Name: {MemberName}

    Membership ID Number: {MembershipID}

    Primary Member Email: {MemberEmail}

    Newborn Name: {NewbornName}

    Newborn DOB: {NewbornDOB}

    Newborn Sex: {NewbornSex}

    Newborn Length: {NewbornLength}

    Newborn Weight: {NewbornWeight}

     

  • Should be Empty: