Membership Registration Form

Complete all sections below. Our administrators will review your application and notify you by email.

Membership Requirements & Fees
✓ One-time Registration Fee: $75.00 (due upon approval)
✓ Annual Administrative Fee: $10.00
✓ Monthly Contribution: $25.00 per bereavement event
✓ Must reside in the Austin / San Antonio metro area
1Personal Information
2Designated Representative

Person to contact and act on your behalf in case of emergency.

3Family Members

List your spouse and/or dependent children who are part of this edir membership.

Full Name Relationship Date of Birth Phone (optional)
4Certification & Signature
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Registration Fee — 1 member
After submitting you will be taken to a secure Stripe checkout. Your application will not be reviewed until payment is received.
Registration fee $85.00
Processing fee (2.9% + $0.30) $2.77

Total charged $87.77
After approval, a recurring annual admin fee will also apply: individual $10/yr · family up to 2 members $20/yr · family up to 3 members $30/yr.
Secured by Stripe  ·  Visa, Mastercard, Amex accepted
You will be redirected to Stripe's secure checkout after submitting.
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