Application Form

Upon submission you will receive a release packet required to be returned by mail for consideration.

Child's Information

Childs Full Name required.Enter childs full name.
Age required.Enter age.
Street Address required.Enter street address.
City required.Enter city.
Select a County.
Select a State.
Zip required.Enter zip code

Parent 1 Information

First name required.Enter first name.
Last name required.Enter last name.
Select relationship.
Email required.Invalid email format.
Add A Parent

Parent 2 Information

Additional Information

Physician's Diagnosis required.Minimum number of characters not met.
Physician's information required.Minimum number of characters not met.
Please make a selection.

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