1 Start 2 Complete Tag #(for Senior Staff use only): Today's Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Last Name: First Name: Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Street Address: City: State: Zip Code: Home Number: Mobile Number: Email: Race: - None -WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian/Pacific IslanderOther Please select all that apply. Ethnicity: - None -Hispanic/Latino/SpanishNon-Hispanic Please select all that apply. Primary Doctor: Phone Number: Address: Medical Conditions: List of all medications: List all allergies: Emergency Contact Name #1: * Emergency Contact #1 Relationship to Member: Emergency Contact #1 Daytime Phone Number: * Emergency Contact Name #2: Emergency Contact #2 Relationship to Member: Emergency Contact #2 Daytime Phone Number: * Yearly Membership Resident: $20 (OFFICE USE ONLY) Yearly Membership Non-Resident: $25 (OFFICE USE ONLY) Date: (OFFICE USE ONLY) Paid: (OFFICE USE ONLY) Received By: (OFFICE USE ONLY)
