Enrollment Form

Membership Level *

SILVER MEMBERSHIP ($5,000 IUA)

GOLD MEMBERSHIP ($1,000 IUA)

Membership Type *

Member

Member + Spouse

Member + Child(ren)

Member + Family

Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Birth Gender *

MALE

FEMALE

Tobacco Use? *

A household member who has used any tobacco product one or more times a month within the past year is considered a tobacco user. Tobacco products include, but are not limited to, cigarettes, cigars, chewing tobacco, snuff, vape products, and pipe tobacco. Smoked cannabis products are considered tobacco for the purposes of the tobacco surcharge. Surcharge +$50/month per household.

YES, AT LEAST ONE MEMBER OF THE HOUSEHOLD IS A TOBACCO USER

NO, THERE ARE NO TOBACCO USERS IN THE HOUSEHOLD

Principles of Membership View Document *

I AGREE TO THE PRINCIPLES OF MEMBERSHIP

Protected Health Information View Document *

I AUTHORIZE ZION HEALTH AND JETTISON TO SEND EMAIL OR TEXT WHICH MAY INCLUDE UNENCRYPTED PROTECTED HEALTH INFORMATION

Pre-existing Conditions View Document *

I HAVE READ AND AGREE TO THE LIMITATIONS ON PRE-EXISTING CONDITIONS WITH ZION HEALTH

Maternity Needs Requests View Document *

I HAVE READ AND AGREE TO THE WAITING PERIOD FOR MATERNITY NEEDS REQUESTS.