Yellow Dot Kit Order Form

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

The Yellow Dot Program is designed to assist first responders by providing quick access to a participant’s medical information in the event of an emergency. Participants receive a Yellow Dot Kit that includes medical information forms, a storage envelope, and special Yellow Dot decals for their vehicle window and home door.

These decals serve as visible "medical alerts," signaling first responders to look for the yellow envelope. This envelope contains important medical details such as a list of medications and existing medical conditions, which can be crucial during an emergency.

The program is free and available to all residents throughout Vermont.

If you are looking to download a blank Emergency Medical Form or to learn more about the program, visit the website.

To order Yellow Dot Kits, fill out the information below.

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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 [for community distribution]
Something else- Write In Please enter an 'other' value for this selection.

2. Please provide your contact information.

First Name *This question is required.

Last Name *This question is required.

Title (if applicable)

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

Phone Number *This question is required.

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.

County