Parent Registration

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HHSC in News
India Abroad (May 2006) HHSC - Khabar (July 2005) HHSC - Helping Kids (July 2003)

	Parent's Information * Indicates a required field.
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	Father's/Guardian’s Information
	* First Name:	* Last Name:

	Mother's/Guardian’s Information
	* First Name:	* Last Name:

	Address
	* Street:
	* City:
	* State:
	* Zip Code:	* Country:

	Alternate Address
	Street:
	City:
	State:
	Zip Code:	Country:

	Phone / Email:
	* Home:	Work:
	Cell:	* Email:

	Emergency Contact
	* Name:	* Relation:
	* Phone:	Alt. Phone:
	Email:

	Physician Information
	* Name:	* Phone:
	Answering Service:
	* Address:

	Dentist Information
	Name:	Phone:

	Insurance
	Subscriber Name:	SSN #:
	Carrier Name:
	Carrier Address:
	Group #:	Group Name:

	Sign In Credentials Please make a note of your login credentials, you will be required to login to the site in order to do the online registration.
	* Login Id:	* Password: