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Back to Schemes & Members

Corporate Scheme Enrolment Form

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Corporate Scheme Enrolment Form

Date:
{{-- Scheme line --}}
Scheme Name:    Scheme Member No.:
{{-- ═════════════ 1. PRINCIPAL DEMOGRAPHICS ═════════════ --}}
Principal Member Demographics
First Name Middle Name Last Name Sex M  F
Date of Birth (DD/MM/YYYY) National ID Number Phone (Primary) Alt. Phone
Physical Address — Estate / Village Sub-County County
{{-- ═════════════ 2. NEXT OF KIN ═════════════ --}}
Next of Kin
Full Name Relationship DOB (DD/MM/YYYY) Phone National ID
{{-- ═════════════ 3. DEPENDANTS ═════════════ --}}
Dependants (Must Be Under 18 Years)
# Full Name Relationship DOB (DD/MM/YYYY) Sex Birth Certificate No.
1
2
3
4
5
All dependants must be under 18 years of age. Attach a continuation sheet if you have more than 5 dependants.
{{-- ═════════════ CONSENT ═════════════ --}}
Data-Sharing Consent & Declaration

By signing this form, I confirm and consent that my scheme and Clara Rosa Hospital may collect, store and process the personal, demographic and dependant information on this form for the purpose of administering my cover.

I confirm the information on this form is accurate, I have read the Privacy Notice below, and I consent freely. I understand I may withdraw consent in writing at any time.

{{-- ═════════════ SIGNATURES ═════════════ --}}
Principal Member · Signature & Date
Scheme Witness · Name, ID, Signature & Date
For CRH Office Use · Received By, Date, Entry No.
{{-- ═════════════ PRIVACY FOOTER ═════════════ --}}
Privacy Notice (DPA 2019): Information collected on this form is processed by Clara Rosa Hospital and the named scheme solely for membership administration, eligibility and billing. Data is retained for seven (7) years from the date of last service and is not shared with any third party except as required by law. You have the right to access, correct or request deletion of your data, and to withdraw consent at any time by written notice to CRH. Complaints may be addressed to the Office of the Data Protection Commissioner, Nairobi.
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