Trellis Enrollment

Your Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Sex at Birth *

Please specify *

What is your Gender Identity? *

Preferred Method of Contact *

Please specify *

Street Address *

City *

State *

ZIP Code *

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 *

Additional Family Members

Number of additional family members *

Additional Info

How did you hear about Trellis?

Personal Information

First Name *

Last Name *

Preferred Name *

Date of Birth *

Contact Information

Work Email * Please use the work email address associated with the employee to verify eligibility.

Phone *

Preferred Email

Address

Address *

City *

State *

Zip Code *

Employer

Sponsor (employer) *

Enrollee *

Demographics

Gender Identity *

Sex at Birth *

Preferred Method of Contact *

Additional Info

How did you hear about Trellis?

Additional Notes

Your Information

Agreements

Who are you registering?

Payment Frequency

Additional Family Members

Additional Info

Personal Information

Contact Information

Address

Employer

Demographics

Additional Info

Thank You!

Family Member