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1Personal Information
First name* Middle name* Middle name (Optional) Last name*
Date of Birth *
2Add Another Applicant (Optional)
You can choose to cover other people in your membership, but please note that you are responsible for paying their membership fees. We accept people of all ages and nationalities on the condition that they have never been diagnosed with cancer before.
Add Another Applicant
3Your Total Premium
Name Chosen Coverage (JD) Annual Premium (JD)
Original Applicant
4Agree to the terms and conditions
Please read carefully through the terms and conditions of becoming a member in the Cancer Care Program and click "I Agree" before proceeding with the rest of the application.

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Membership Conditions
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"I hereby verify on my behalf and on behalf of any additional members that I have included in this application that: 
I and any additional members that I have included in this application are currently free of, and have never been diagnosed with cancer. If proven otherwise, I understand and accept that the King Hussein Cancer Foundation/ Cancer Care Program will cancel my/our membership and in such a case I wholly and irrevocably agree to reimburse any financial expenses incurred by the Program/Foundation to cover my treatment or the treatment of any family members included in this application. 
  1. I have fully read and reviewed all the terms and conditions of Cancer Care Program, and the benefits provided in the event of being diagnosed with cancer or lack thereof (as outlined in this application) and I agree to all its contents. 
  2. In the event that I or any additional members that I have included in this application are diagnosed with cancer, I agree to immediately inform the Program administration. 
  3. I understand that in the event I do not inform the Program, I lose the right to benefit from any treatment coverage after the expiry of my membership. 
  4. I irrevocably authorize my treating physician, and any medical institution, commission, or person who has knowledge or information regarding my medical history or that of any additional members included in this application to release this information to the King Hussein Cancer Foundation Cancer Care Program, including hospital records or any other medical records as related to consultations, diagnosis or treatment. 
  5. I certify that all the information provided in this application and its attachments is complete and correct and understand that it forms an integral part of the approval and authorization process. I understand that it is my responsibility to inform the King Hussein Cancer Foundation/ Cancer Care Program of any changes to the information provided in this application. 
  6. Should the King Hussein Cancer Foundation/ Cancer Care Program approve my/our membership, I understand that this application is considered the basis for this approval and its validation. Any information that has been concealed in order to obtain the King Hussein Cancer Foundation/ Cancer Care Program’s approval will cause my/our membership to be immediately canceled. 
  7. This Agreement, and all Program membership rules and conditions, adhere to current Jordanian laws. Any dispute in connection with this agreement shall be settled by Amman Court (Palace of Justice). 
    I undertake that I and any additional members included in this membership application are fully aware of all membership conditions in the Cancer Care Program, and agree to any approval or authorization decisions  concerning my membership.
    In the event that any wrong or misrepresented information I have provided causes my/our cancer treatment coverage to be canceled, I agree to reimburse the Program for any and all expenses paid for my treatment or the treatment of any additional members included in this application.