Enrollment Application Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Email* Address Street Address Apt/Unit/etc. City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Spouse's Name(If applicable) Spouses Phone(If applicable)Enrollment ApplicationOur current enrollment period is a maximum of 1 year or sooner (if any of your current circumstances change). Therefore, if your residence, income, or insurance status changes, it is important for you to notify Open Bible Medical Clinic & Pharmacy about that change right away. Certain changes may result in OBMC&P being unable to provide services. Open Bible Medical Clinic & Pharmacy will attempt to contact you one month before your current enrollment expires to re-evaluate your need and/or eligibility for an additional period of assistance.Do you have any insurance including government coverage?* Yes No Are you between the ages of 18 and 64 years old?* Yes No Are you able to show proof that you live in El Paso or Teller County, Colorado?* Yes No What is your monthly household income (this includes you and any family members living with you)?*How many people in the home are dependent on the household income?*IMPORTANT NOTICESMedications are to be dispensed in 30-day increments only. There is also a cap on the amount of pain medica-tions dispensed here OBMC&P. Pain medications are limited to a 60-day supply in a 12-month period per patient. Appointment Cancellation Policy: Making your scheduled appointments is an integral part of the quality of care we strive to administer as well it is an important part of our efficiency and flow as a Clinic. Therefore it is important for you to make your scheduled appointments. If you must cancel your appointment please call and do so a week before your appointment. Calling the day of your appointment does not allow us ample time schedule another patient needing care. After 3 missed appointments you will be unenrolled in our program and will have to go through the eligibility process again to be reinstated. Please keep in mind that our Medical Personnel, Eligibility Staff, and Receptionists are ALL VOLUNTEERS – who are willingly taking time away from their families and busy schedules to serve you in this way! We request that ALL of our patients SMILE and be KIND, RESPECTFUL, and PATIENT throughout the duration of this process! These wonderful volunteers are here not because they have to be but because they want to be! I acknowledge & understand this notice.