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ABCD Registration

Before you begin to fill out the online enrollment form, please make sure you have the child's current medical coupon with PIC number on hand.

Please fill out the following application. If you have any problems, e-mail kgc.oralhealth@kingcounty.gov.

"*" indicates required field.

Parent or guardian's personal information

First name*:

  

Middle initial:

Last name*:

  

Relation*:

  

DOB*:

    (e.g, 04/12/1969)

Parent or guardian's contact Information

Street address*:

  
City*  

Zip code*: 

  -  

Telephone*:

   (e.g., 111-111-1111)

Alternate telephone*:

 (e.g., 111-111-1111)

Email address

Specific needs

First language*:

Interpreter required?

Transportation assistance required?

Number of miles willing to travel*?

 

Special needs / requirements 

 

From which organization are you registering to ABCD*?

  

 

Updated: March 19, 2007


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