Ghana Care Ltd.

• Interested individuals please complete the following and mail together with the appropriate annual fee. You are to contact the member(s) residing in Ghana, immediately, to make an introduction to the hospital you have chosen.

• First print this application. Fill out completely then make Check Payable to: Health Africa/Ghana Care

P.O. Box 20298
Shaker Heights, Ohio 44120
U.S.A.
Toll Free 1.888.505.6566
 


:: SPONSOR INFORMATION
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First Name Middle Name Last Name
     
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Address
 
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City State/Province Zip/Postal Code
     
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Country Telephone Social Security Number
     
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Where did you hear about us?    



:: MEMBER INFORMATION
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Plan  
Class
     
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Selected Hospital/ Clinic Number   City
     
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Individual Name if Husband/Wife included, give name Age
     
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Name of Children 1, if any
Age
   
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Name of Children 2, if any
Age
 
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Name of Children 3, if any
Age
 
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Address
 
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City State/Province Zip/Postal Code
     
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Country Telephone  
 
 
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Sponsor’s Signature   Date