Access Membership Application Access Membership Application MEMBERSHIP INFORMATION Which Membership would you like to purchase? * $40.00 = 4 PERSON$100.00 = 4 PERSON + BUTTERFLY ENCOUNTER$60.00 = 6 PERSON$150.00 = 6 PERSON + BUTTERFLY ENCOUNTER PRIMARY CARDHOLDER (Must be 18+) This will be the primary person who owns the Membership and meets the required Access eligibility requirements. Must be someone over the age of 18. Name * Name First First Last Last Phone * Email * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal SECONDARY CARDHOLDER (Must be 18+) This is a second person who will be named on the Membership (not required) and can use the Membership anytime but cannot make any changes to the Membership. Must be someone over the age of 18. Name Name First First Last Last Relation to Primary Cardholder Spouse Grandparent Caregiver OtherOther ELIGIBILITY VERIFICATION All forms of verification submitted must be in the same full name and have the same address as the PRIMARY CARDHOLDER above. FRONT PHOTO OF PRIMARY CARDHOLDER CT OR MA DRIVER'S LICENSE * Drop a file here or click to upload Choose File Maximum file size: 134.22MB BACK PHOTO OF PRIMARY CARDHOLDER CT OR MA DRIVER'S LICENSE * Drop a file here or click to upload Choose File Maximum file size: 134.22MB FRONT PHOTO OF (1) OF THE FOLLOWING: EBT Card | Husky A or C Insurance Card | MassHealth Insurance Card * Drop a file here or click to upload Choose File Maximum file size: 134.22MB BACK PHOTO OF (1) OF THE FOLLOWING: EBT Card | Husky A or C Insurance Card | MassHealth Insurance Card * Drop a file here or click to upload Choose File Maximum file size: 134.22MB If you are human, leave this field blank. Submit
