How can I participate in Yellow Dot?


You can request a Yellow Dot packet to be mailed to you by supplying your name and address in the participation form below. PLEASE NOTE: Only one folder is needed per vehicle. If you have multiple people riding in the same vehicle who want to participate, you can print a medical information sheet for each participant from the Yellow Dot Materials page and insert those sheets in the folder.

Due to the large volume of Yellow Dot packet requests, please allow for a few weeks for your packets to be mailed to you. Requests for individuals are being given priority for filling with available supplies.

Once your request is submitted through the form below, you may submit any order inquiries to Ra-penndotsalesstore@pa.gov.

Contact Individual

Date:
First Name:
Last Name:
Email:
Phone Number:
Address 1:
Address 2:
City:
State:
ZIP:
Requested Number of Packets: