Use this form to pay for member fees & submit member forms.

1Submit Forms > 2Payment Method > 3Review Your Entry > 4Payment
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Providers First and Last Name: *
Healing Priory/Center Name: *

If you do not have your own healing priory or work at a healing priory, please put "N/A".
Select all membership types that apply to the forms you are submitting at this time: *

Select all membership types that apply to the forms you are submitting at this time: Membership- $35.00 Spouse (Included) Adult children memberships- Adult child must be between the ages of 19-26 years old, living at home & unmarried. The child must be signing up with a parent or have a parent who is a current member. (Included) Minor Children- 18 years old and under. The child must be signing up with a parent or have a parent who is a current member. (Included) 1 Day Membership- $5.00 Reprint of membership card (Membership Cards are given at the request of the Provider)
How many members are signing up for the $35.00 membership? *
Please type the first and last names of the members who are signing up for the ($35.00) membership: *

*We MUST have the names typed on this list to verify the correct spelling.
How many adult children are signing up in a family membership (Ages 19-26, unmarried & living at home) *
Please type the first and last names of the adult children who are signing up: *

*We MUST have the names typed on this list to verify the correct spelling.
How many minor children are signing up under a their parent's membership (family membership)? *
Please type the first and last names of the children who are signing up under their parent's membership: *

*We MUST have the names typed on this list to verify the correct spelling.
How many individuals are signing up for a 1 day guestpass? *
Please type the first and last names of the members who are signing up for a 1 day guestpass: *

*We MUST have the names typed on this list to verify the correct spelling.
How many membership cards are being reprinted? *
Please type the first and last names of the members who are having a card reprinted: *

*We MUST have the names typed on this list to verify the correct spelling.
If you have additional notes for our office, please leave them here after you type the names.
How will you be submitting the member forms for these patients/clients? *

How will you be submitting the member forms for these patients/clients? Attached to this form (Preferred Method) Mail (Po Box 70 Dry Fork, VA 24549)
Please upload all member forms here.

*If member forms are not completely filled out, they WILL NOT be processed. Please make sure all applicable fields are filled out. If you take pictures of the forms instead of scanning them in, they WILL NOT be accepted. *

Attach Files

We strongly suggest that member forms be uploaded as ONE file. This saves time for our providers and our office. To do this, you can scan your forms in and save them as one file or you can combine the files after scanning them into your computer, by using a program like Adobe Acrobat.
Please note, there may be an additional delay in the processing of members if you choose to mail the member forms instead of attaching them to this online form.
$0

Total

Use this form to pay for member fees & submit member forms.

Use this form to pay for member fees & submit member forms.

$`0`

Total

Please note, there may be an additional delay in the processing of members if you choose to mail the member forms instead of attaching them to this online form.

$`0`

Total

Use this form to pay for member fees & submit member forms.

Use this form to pay for member fees & submit member forms.

$0

Total

Please note, there may be an additional delay in the processing of members if you choose to mail the member forms instead of attaching them to this online form.

$0

Total

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