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Our Story
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ENROLLMENT
Deputy Sheriffs' Association
Authorization and Payment Plan
Name
*
First Name
Last Name
Street Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Work Phone
(###)
###
####
Email Address
*
Deputy's Name
Print full name (first, middle and last)
Employee ID Number
*
Person to Contact in Case of Emergency
Person to contact in case of emergency: _____________________________________________ (not living at same address) Please include Name and relationship, Street Address, and Contact Information
Checkbox
*
The above authorization will entitle each deputy who is currently a dues paying member of the Deputy Sheriffs' Association of San Diego County; their spouse/domestic partner (as defined in the M.O.A.), minor children, or minor stepchildren living in the deputies home; to chiropractic care and massage at specific locations. This authorization shall remain in effect for a period of no less than ONE YEAR, unless just cause is presented to ADMINISTRATIVE HEALTH FUND by the DSA member. This authorization will be discontinued only upon receipt of a written request by the member, with a reasonable amount of time to act on said request. The Deputy Sheriff's Association of San Diego County is held harmless for any fees due but not collected. It is the member's responsibilityt to contact ADMINISTRATIVE HEALTH FUND within 10 days if any of the above information changes. ****** My acknowledgement below indicates, under penalty of perjury, that the above information is true and correct, and that I have read, understand and accept all terms of this agreement.
I Agree
I Disagree
Thank you!
