Yellow Dot Order Form

The Yellow Dot Program is designed to help first responders quickly access important medical information to better help you or your family in an emergency.
If you are looking to order a blank Emergency Medical Forms or to learn more about the program, visit the website.

To order a Yellow Dot Kit, fill out the information below.

______________________________________________________________________________________________________________________________________

1. Are you ordering Yellow Dot kits for an organization or for a family/individual? (select all that apply) *This question is required.

Family/individuals
Organization
Something else- Write In Please enter an 'other' value for this selection.

2. Please provide your contact information. *This question is required.

First Name *This question is required.

Last Name *This question is required.

Email Address *This question is required. This question requires a valid email address.

Home/Mobile Number *This question is required.

3. Organizational Name

3. Please provide your mailing address to send your order. *This question is required.

Mailing Address including Apt/Suite/Office/P.O. box if applicable *This question is required.

City *This question is required.

State *This question is required.

Zip *This question is required.

4. Who are you ordering for? (select all that apply) *This question is required.

Myself
Youth
Youth in car seat or booster seat (theses kits will include a car seat sticker)
Other adult family members/neighbors
Other - Write In Please enter an 'other' value for this selection.

4. How many people are you ordering kits for?

Each person should get one (1) Yellow Dot Kit. Each Yellow Dot Kit contains all necessary forms and materials for 1 vehicle and 1 home per person.
*This question is required. This question requires a valid number format.

Yellow Dot Kits

5. Select decals options for your kit:
The Yellow Dot decals are for your car and home. First responders are trained to look for these decals when arriving to an emergency, which will alert them to look for the emergency information kits.

Currently, we have three decal options to choose from.
"Face Cling Decal"- This removable static cling is placed on the INSIDE of the glass and can be seen through the glass.
"Back Cling Decal"- This removable static cling is placed on the OUTSIDE of the glass and can be seen from the outside.
Reflective Sticker Decal- This permanent sticker is applied on a surface (like how normal stickers work).

You will receive 2 decals in a folder. Please choose your options below.

I want my kits to have *This question is required.

5. Confused?
If you are not sure what kind of kit you are looking for, please describe where you will place the decals.

5. Briefly share how your organization plans to distribute Yellow Dot Kits in your community? *This question is required.

5. Do you have any suggestions or feedback regarding the Yellow Dot Program?

6. Are you willing to participate in a short follow-up email survey regarding the Yellow Dot program? *This question is required.

Yes
No
Not Sure

7. Where did you hear about the Yellow Dot program? (Check all the apply) *This question is required.

Radio
Social Media (i.e Facebook, X (formally Twitter) or Instagram)
First Responder Service (i.e EMS or police department)
Community organization (i.e senior center or library)
Face to Face community event (i.e fair or open house)
Healthcare Provider (i.e primary care provider)
Other - Write In Please enter an 'other' value for this selection.

Yellow Dot Order Form

During an emergency on the road or at home, time can be critical.