Fellows’ Housing and Health Form Please complete the form below. The information that you provide will assist us in making housing assignments. About You Name * Email * Date of Birth (MM-DD-YYYY) * Country of Citizenship * Please list the names of the family members accompanying you. Please note the profession of your partner/spouse, and the ages and genders of children. Health Information Do you or members of your family have any dietary restrictions or food allergies? * Yes No If "Yes," please explain. Do you or members of your family have any other medical allergies? * Yes No If "Yes," please explain. Do you or members of your family have any disabilities? * Yes No If "Yes," please explain. Additional Information Do you plan to bring a vehicle with you? * Yes No If "Yes," please provide the color, make, model, and license plate number. Emergency Contact Information Please provide the information for two emergency contacts below. Emergency Contact #1 Name * Relation Phone Number * Emergency Contact #2 Name * Relation Phone Number * By submitting this form you agree that the above information is correct to the best of your knowledge. If you are human, leave this field blank.