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First Name: [current-user:profile-profile:field-first-name] 

Last Name: [current-user:profile-profile:field-last-name]

Do you want us to report to CE Broker? [current-user:profile-profile:field-custom-ceb-toggle]

Do you want us to report to NYCA? [current-user:profile-profile:field-custom-nyca]

Do you want us to report to PA? [current-user:profile-profile:field-custom-child]

Last five digits of SSN: [current-user:profile-profile:field-custom-ss]

Date of Birth: [current-user:profile-profile:field-custom-dob:ethosce_short_no_time_full_month]