SCRIP Registration Form
Email address *
Parent's Name *
Your answer
Student's Name *
Your answer
I designate my rebates to go to ONE of the following: *
I authorize HCA to release my SCRIP order to my child. By answering YES I agree not to hold HCA or the Scrip program liable for any lost, stolen or misplaced SCRIP once it has been released to my child. *
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