Online Child Application

Please fill out to the best of your ability and then hit the “Submit” button at the bottom of the page.
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Child Application

  • Please enter a value between 5 and 18.
  • List medication name, Dr. who prescribed it, reason needed and how long the child has been taking the prescription.
  • List then explain
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    Check each box that applies.
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  • Signature of Guardian
  • Signature of Child