Step #1 - Enter Your Information
Name:
Address: ,
Phone Numbers:
Insurance Carrier:
Registration Agreement: View Agreement Terms
Physician Name:
Address:
Hospital Preference:
Medical Release : In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician)
Medical Release Signature:
Zero Tolerance Acknowledgement: View Agreement Terms