To become a member of the Life Raft Group, fill out the membership application below.
All information is confidential.

Information provided will be kept strictly confidential and is for the internal use of the Life Raft Group only. We are committed to protecting the privacy of our members. Any data or information that we share in any way is always cleansed of any identifying information in order to protect confidentiality.

If you fax the form, make sure that your contact information (phone or email) is on the first page you send. Occasionally people send failed faxes with no way to contact them.  Why join? Read more…

If you want to view the form in Spanish, click the dropdown on the top right of the form.
Si quiere rellenar el formulario en español, haga clic en el desplegable de la parte superior del formulario de la derecha.

Next Steps:

If you are already an LRG Member
Update Your Medical History

Core Values