COVID-19 Testing Registration

Which best describes you?

Affiliation

What is your preferred Email?

Preferred Email Confirm?

What is your primary phone number?

Are you able to receive SMS text messages on this phone? Note: SMS text communications will be limited

NoYes

Preferred Written Language (Spanish/English available)

Preferred Spoken Language (Spanish/English available)

UO ID (95#)

Confirm UO ID (95#)

Chapter Affiliation

First Name

Middle Initial? If you do not have a middle initial, please leave this blank.

Last Name

Guardian First Name

Guardian Last Name

Minor's Age

Date Of Birth (mm/dd/yyyy)

Gender

Race

Ethnicity: Hispanic or Latino Origin?

Insurance Company

Name of Insured

Relationship to Insured

Member ID

Group Number

Subscriber Date of Birth

Street Address 1

Street Address 2

City

State/Province

ZIP/Postal Code

County

Lane County, Other

Emergency Contact Name

Emergency Phone Number

Relationship to you (e.g. parent, spouse, roommate)

Address 1: Phone