Senior ID Card — Data Entry

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Current Date

Please select today’s date.

Resident Photo

JPG/PNG, up to 5 MB.

Please select a JPG or PNG photo.

Applicant

Full Name

Full Name is required.

Date of Birth

DOB is required.

Address

Address is required.

Phone Number

Phone number is required.

Gender

Gender is required.

Hair Color

Hair color is required.

Eye Color

Eye color is required.

Height

Height is required.

Weight

Weight is required.

Blood Type

Blood type is required.

Medical

Medical Conditions

Medical conditions are required (use “None” if none).

Allergies

Allergies are required (use “None” if none).

Primary Doctor’s Name

Doctor’s name is required.

Primary Doctor’s Phone

Doctor’s phone is required.

Emergency Contacts

Emergency Contact 1 — Name

EC1 name is required.

Relation

Relation is required.

Phone

Phone is required.

Emergency Contact 2 — Name

EC2 name is required.

Relation

EC2 relation is required.

Phone

EC2 phone is required.