MEMBER ENROLLMENT Select ActionEnroll New MemberSend Information To MemberSend Information To LeadName* First Last Email* Enroll MemberDesired Service*Tele-MedicineSelect Activation Fee*Activation Fee ($24.95)Activation Fee ($19.95)Activation Fee ($14.95)Activation Fee ($9.95)Waive Activation FeeSelect Access*Monthly Access at $5 Per MonthRx Savings CardTotal Due Today $0.00 This amount is due today, and the member's payment card will be charged $5 per month until they cancel.Member Name* First Last Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Telephone Number*Gender*Please SelectFemaleMaleDate of Birth*This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Payment Information* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Terms and Conditions* Customer authorizes Sociallity to charge their credit card or debit card the amount due for membership activation fee and the first month membership fee Customer authorizes Sociallity to automatically charge their credit card or debit card the monthly membership fee until such a time that Customer elects to cancel their membership. Customer acknowledges and understands that they may cancel the program access at any time without penalty. Customer acknowledges, agrees to, and accepts the Sociallity Privacy Policy, the Sociallity Website Use Terms and Conditions, and the Sociallity AccessNow Terms and Conditions. Customer acknowledges that they understand that none of the programs or services made available to them by Sociallity are Insurance products and are in no way to be considered Insurance.