Enrollment Form
Your Information
First Name
*
Last Name
*
Email
*
Agreements
I have read and accept the
membership agreement
*
I confirm that Medicare is not my primary insurance
*
I understand Trellis is not health insurance
*
Who are you registering?
Myself
An adult other than myself
A child (<18 years)
Multiple adults and/or children
Payment Frequency
Select payment frequency
*
-- Select --
Monthly
Annually
Additional Family Members
Number of additional family members
*
-- Select --
1
2
3
4
5+
Submit Enrollment
Submitting...
Family Member
Relationship
*
-- Select --
Spouse
Child
Other
First Name
*
Last Name
*
Email (optional)
Phone (optional)