Please follow the instructions in filling out the medical registration form below and additional pages following. All submitted information is kept private. We will review your information and contact you once we determine your eligibility. Thank you for contacting ARCH!

Medical & Contact Information

Name * First Last
Date of Birth * / MM / DD YYYY
Gender *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Primary Care Giver *
Relationship *
Phone * - (###) - ### ####
Primary Email *
Secondary Email
Mother's Name First Last
Phone - (###) - ### ####
Address (if different than above)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Father's Name First Last
Phone - (###) - ### ####
Address (if different than above)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Additional Emergency Contact Name * First Last
Phone * - (###) - ### ####
Disability *
Visual/Hearing Concerns (glasses, hearing aids, etc.)
Orthopedic Concerns (braces, crutches, wheelchair, etc.)
Seizure? * Yes No
If Yes, What Type?
Allergies? * Yes No
If Yes, What Type?
Description of drug and/or allergic reactions
Significant Illness/Operations
Special Needs/Comments (assistance w/money, bathing, dressing, dietary needs, behavioral problems, sleep disturbances, etc.)
Doctors Name * First Last
Phone * - (###) - ### ####
Doctors Address (or place of practice) *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Health Insurance Carrier
Member No.
Medication *
Dosage *
Time(s) Given *
Medication
Dosage
Time(s) Given
Medication
Dosage
Time(s) Given
This is my permission from above named to participate in ARCH activities. I will make certain he/she is in good health. I authorize ARCH Staff to dispense medication and secure medical treatment if necessary in the event of an emergency. I also waive all liability for any accident on the part of ARCH and/or Staff and will not hold ARCH responsible.
Name * First Last
Date * / MM / DD YYYY
I grant permission to ARCH to use the likeness, voice, and words of above in TV, newspapers, film and other media for the purpose of communicating the activities of ARCH, and in appealing for funds to support such activities.
Name First Last
Date / MM / DD YYYY
Name of Legal Guardian * First Last
Phone * - (###) - ### ####
Race (for government census purposes only)

Contact Information

ARCH
1550 West Colter Street
Phoenix, Arizona 85015
[ directions ]

P: (602) 230-2226
F: (602) 230-0308