If you would like to fax in this form, please enter your email address in the box, and we’ll mail you a printable version of this form. Email address: I have read the literature describing the AIM Platinum Plan and also the AIM Gold Plan and hereby enroll my son/daughter in the following plan: CHOOSE THE PLAN OF YOUR CHOICE GOLD PLAN MEDICAL COVERAGE in Israel for the full year $520.00 Before Aug. 1, 2019Start Date: $575.00 After Aug. 1, 2019Start Date: $375.00 for Six(6) months coverageStart Date: PLATINUM PLAN ADVANCED MEDICAL COVERAGE in Israel for the year $640.00 Before Aug. 1, 2019Start Date: $695.00 After Aug. 1, 2019Start Date: $475.00 for Six(6) months coverageStart Date: *Last Name *First Name Middle Name *Please Note Required Fields *Home Address *CountrySelect CountryArgentinaAndorraBrazilCanadaChileDenmarkFinlandFranceGermanyGreeceHollandHondurasItalyMexicoPanamaSpainSwedenUnited KingdomUSAVenezuela *City *State *ZIP Passport # Social Security # *Birth Date: *Email (Parent/Guardian) *Home Phone Mobile Office Phone FAX Email (Student) * Present School or Last School Attended *Yeshiva Attending in Israel or Address in Israel The applicant has the following medical condition. The Applicant has received thefollowing medical care/medicationsin the last 12 months. The information above does not excuse the necessity of submitting a Medical History form as required. Upload A Photo Insurance Carrier Insurance Address Policy number I have read and agree to the Terms & Conditions of the AIM enrollment application. I agree to pay for all other medical and dental services incurred by the above named registrant, which services are not coveredby the terms and conditions of this agreement and by pressing SUBMIT below, request registration for my child on the AIM plan.
