Name: | DOB: | MRN: | PCP:

Online Enrollment form

Thank you for your interest in Dayton Children's MyKidsChart, an easy-to-use tool that provides you quick and secure online access to some of your child's health information. To sign up for access to your child's Dayton Children’s MyKidsChart record, please complete and submit the following form for approval. Once your request has been received, we will send you an activation code within 3 business days.

Please note there could be a delay with processing your request due to, but not limited to the following reasons:

1. If your child is 18 years or older, you will no longer have access to your child's Dayton Children’s MyKidsChart record.

2. If we are unable to verify the requesters identity based on the information provided below.

Parent/Legal Guardian Information:

Requesting Access for:

Child Information:

Relationship to child:
*Legal Guardianship papers must be on file before full access can be granted.

Additional Child Information:

Relationship to child:
*Legal Guardianship papers must be on file before full access can be granted.

Additional Child Information:

Relationship to child:
*Legal Guardianship papers must be on file before full access can be granted.

How would you prefer your activation code be delivered?

Delivery Methods:
You must have the Email or Cell Phone number populated above in order to send to the preferred method.

PLEASE READ AND CERTIFY

I am the parent or legal guardian of the child and/or children listed above and that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand this Dayton Children's MyKidsChart Consent Form and I agree to its terms and conditions. I hereby request access to my child and/or children's online health record.

I Certify