Personal Profile Questions |

Legal First Name*

Legal Last Name*

Primary Email Address*

Demographics

Are you a tobacco user?*

Yes
No

Are you covered by the Medicare program?*

Yes
No

Are you covered by the Medicaid program?*

Yes
No

Disability

Do you have a Disability or have a history/record of having a Disability?*

Yes
No

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

Autism
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or hard of hearing
Depression or anxiety
Diabetes

Epilepsy
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Intellectual disability
Missing limbs or partially missing limbs
Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
Psychiatric condition, for example, bipolar disorder, schizophrenia,PTSD, or major depression

Veteran

Are you a Protected Veteran?*

Yes
No

As a Protected Veteran select all that apply:*

Disabled Veteran
Recently Separated Veteran
Active Duty Wartime or Campaign Badge Veteran
Armed Forces Service Medal Veteran

Discharge Date*

Emergency Contacts

Emergency Contact Full Name*

Relationship*

Emergency Contact Phone Number*

Personal Profile Questions