Trellis Participant Application

If you are new to Trellis programs, please complete this application and a team member will contact you within 3 business days. If you are unsure which program is the best fit, please contact shelly@trellishta.org.

We request that you be able to commit to at least 8 sessions so that you can fully benefit through regular participation. Becoming a regular participant will allow you to build important social connections and make progress towards your personal  health and wellness goals.

The personal and medical information that you provide on this form will be managed by Trellis as confidential. Demographic information may be used to report to grant funding agencies.

Required for first-time applicants. Paper application is available upon request.

Program of Interest: *
Gather & Grow: Thursday group or Friday group? *

Emergency Contact #1

Emergency Contact #2

Do you have a disability? *
Do you have allergies? Include food allergies. *
Are you prone to skin breakdown?
Do you currently have a skin breakdown?
If Yes, is skin fully healed?

Medical History

Do you currently have, or have you ever had any of the following conditions? (Check all that apply.)

Demographic Information

The following information is necessary to receive funding for our programs.

What is your race?
What is your ethnicity? *
What is your age? *
How do you describe yourself? *

Health Insurance Coverage

Are you, the participant, currently covered by any of the following types of health insurance or health coverage plans?