Health Information Emergency InformationToday's Date* MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY Age* Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Who can we call in case of EMERGENCY?Name* First Last Relationship* Phone*Health InformationDiabetes?* Yes No If YES to Diabetes, where do you carry your supplies? Do you have any allergies? Examples: Bee/Insect, Milk, Wheat/Gluten, Tree Nuts, Peanuts, Dye (Color), Shellfish, Dairy/Lactose, Latex, etc. Allergies (Food) Allergies (Environmental) Allergies (Animals) Other allergies? Do you carry an inhaler?* Yes No Do you carry an Epi-Pen?* Yes No Δ Return to Enrollment Forms
