Valley Children's Healthcare MyChart Proxy Activation Request

Thank you for your interest in Valley Children's Healthcare's MyChart, an easy-to-use internet tool that provides you quick and secure online access to certain protected health information regarding your child. To sign up for access to your child's MyChart record, please complete and submit the following form for approval. We will contact you if we have any questions regarding your information or require additional information to process your request.


Parent/Legal Guardian Information


Child Information

Is the child 18 years of age or older?
Are you requesting access for an adolescent with diminished capacity?
Relationship to Child:
*Diminished capacity is defined as being legally and/or clinically determined unable to make medical decisions.

Child Information

Is the child 18 years of age or older?
Are you requesting access for an adolescent with diminished capacity?
Relationship to Child:

Child Information

Is the child 18 years of age or older?
Are you requesting access for an adolescent with diminished capacity?
Relationship to Child:


I hereby request access to the online health record, provided through Valley Children's MyChart, regarding the above-name patient.

I hereby certify the above

Do not use this form for medical emergencies.

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