INSTRUCTIONS: Click on the link above and fill in the following information.

1. Enter Parent’s phone number

2. Enter Parent’s address

3. Enter Child’s Gender

4. Enter Child’s Date of Birth

5. Enter Child’s School Grade (Leave blank if not in school)

6. Enter Child’s Medical Note

7. Enter PARENT’S Email Address

8. SUMBIT AS SOMEONE ELSE> Enter CHILD’S Name

Fill out a separate form for each child.

If you have any questions please call Tricia at our office. 606-843-6211. Thank you!