Name: | DOB: | MRN: | PCP:

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

Relationship to Child:
*Legal Guardianship papers, including but not limited to court orders, must be on file before access can be granted.

Additional Child Information

Relationship to Child:
*Legal Guardianship papers, including but not limited to court orders, must be on file before access can be granted.

Additional Child Information

*Legal Guardianship papers, including but not limited to court orders, must be on file before access can be granted.


I am the birth/adoptive parent or legal guardian of the child and/or children listed above and all information that I have provided is true and correct. By signing this form, I acknowledge that I have read, understand and agree to this Proxy Activation Request and Terms and Conditions of Use Agreement. I further understand and acknowledge that Valley Children’s Healthcare is relying on the accuracy and completeness of the information I have provided in this form to determine the requested proxy access request.

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

I hereby certify the above

Do not use this form for medical emergencies.