MyChart -

Parent/Legal Guardian Information

First Name:

Middle Name:

Last Name:

Date of Birth (xx/xx/xxxx):

Address:

City:

State:

Zip Code:

Phone (xxx-xxx-xxxx):

Email Address:

Drivers License or State ID Number:

Requesting Access for:

Existing Akron Children's MyChart AccountNew Akron Children's MyChart Account

Child Information

Child's First Name:

Child's Middle Name:

Child's Last Name:

Date of Birth (xx/xx/xxxx):

Your relationship to the patient:

MotherFatherLegal Guardian*Residential Grandparent*

*Legal Guardian must have a copy of court order supporting legal guardianship.

*Residential Grandparent must provide either a Grandparent Power of Attorney or a Caretaker Authorization Affidavit.

Additional Child Information

Child's First Name:

Child's Middle Name:

Child's Last Name:

Date of Birth (xx/xx/xxxx):

Your relationship to the patient:

MotherFatherLegal Guardian*Residential Grandparent*

*Legal Guardian must have a copy of court order supporting legal guardianship.

*Residential Grandparent must provide either a Grandparent Power of Attorney or a Caretaker Authorization Affidavit.

Additional Child Information

Child's First Name:

Child's Middle Name:

Child's Last Name:

Date of Birth (xx/xx/xxxx):

Your relationship to the patient:

MotherFatherLegal Guardian*Residential Grandparent*

*Legal Guardian must have a copy of court order supporting legal guardianship.

*Residential Grandparent must provide either a Grandparent Power of Attorney or a Caretaker Authorization Affidavit.

PLEASE READ AND CERTIFY

I am the parent or legal guardian of the child and/or children listed above. All information I have provided is correct. By signing this form, I acknowledge that I am authorized to access information on the above patient(s) via MyChart according to Akron Children's Hospital terms and conditions.

Click the statement to the right to sign this form electronically (It will turn blue when clicked):

Yes, I certify that I have the legal right to this minor's medical information.

Akron Children's MyChart Proxy Enrollment Form

Parent/Legal Guardian Information

Child Information

Additional Child Information

Additional Child Information

PLEASE READ AND CERTIFY