PCHAP - Pastor's Care Health Assistance Program

Appendix A: Personal Information

Surname

First Name

Civil Status

Birthday

Nationality

Email Address

Home Mailing Address (Philippines)

Job Title / Occupation

Source of Funds

Supervisor Information

Supervisor Name

Role / Position

Phone Number

Email Address

Church Outreach

SSS / Passport No.

PhilHealth / TIN

F. Immediate Family / Beneficiaries

Children 18 years old and below may be listed.

First Name	Last Name	Date of Birth	Relationship

Appendix B: Health History

Height (cm)

Weight (kg)

Has there been a weight change of > 4kg in the last 12 months?

Yes No

A. Cardiovascular

High blood pressure Chest pain Stroke

B. Endocrine

Diabetes Thyroid disorder

C. Urinary / Reproductive

Kidney disorder Bladder infection

D. Cancer / Others

Cancer / Malignancy Arthritis / Gout

For Women Only

Are you pregnant?

Yes No

If yes, how many months?

Appendix B: Member Acknowledgment

Please certify each statement to proceed.

PCHAP is Not Insurance: I understand PCHAP is a mutual aid program, not a guaranteed insurance plan.

Fund Availability: I acknowledge assistance is subject to fund availability and Board approval.

Waiver of legal Claims: I agree not to file legal action if assistance is denied.

Non-Refundable: All contributions are non-refundable and non-transferable.

6-Month Rule: I must contribute for 6 months before being eligible for assistance.

Suspension: I aware that 3 missed payments lead to suspension.

Accuracy: I certify that all documents and information provided are honest and accurate.

Final Step: Document Upload

Please upload clear copies of the following documents.

Payment Instruction

Please remit your initial contribution of 500 PHP to:

Bank Name: Development Bank of the Philippines (DBP)
Account Name: Jesus Reigns Ministries, Inc.
Savings Account Number: 00-5-02917-411-6
Branch: DBP Manila-Nakpil

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Initial Payment Receipt

Application Summary

By clicking "Submit Application", you certify that all the above information is correct and you agree to the PCHAP terms.

Membership Application