Medi-Share Group Registration Form

* Indicates Required Field

Organization Information


For Church Use Only


Group Administrator Information

Please enter the information for the Group Administrator below. This person will be designated as the primary member for your Medi-Share group.

Individual Head of Household Applicants

Please enter the details below for each individual applicant in the group. Include yourself as an individual applicant if you plan to apply.

For households with more than one employee applicant, please contact us for further instructions at (877) 564-7687.

Applicant 1

Group Administrator Signature