This form must be completed by a parent and by your pediatrician.
Please return the form to us as soon as possible - no later than June 1.
Return the form to us in one of these ways:
- Scan and email us at email@example.com
- Fax the form to (718) 788-3214
- Mail the form to us at 378 3rd Street, Brooklyn NY 11215
- Scan and upload the form using the button below (make sure file is in .pdf format)