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Email*

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Password*

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(at least 6 characters)

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{petclienttext:caption}
{petclienttext:body}
{petclienttext:validation}
{petclienttext:description}
How did you hear about us?*

Please Select One

Please tell us where you heard about us.*

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{whoareyousigningup:caption}*
{whoareyousigningup:body}
{whoareyousigningup:validation}
{whoareyousigningup:description}
{adult name:caption}*
{adult name:body}
{adult name:validation}
{adult name:description}
Client First Name*

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Client Last Name

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{Weight:caption}*
{Weight:body}
{Weight:validation}
{Weight:description}
Diagnosis*

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{Date:caption}
{Date:body}
{Date:validation}
{Date:description}
Client Year of Birth*

Please enter the four digit birth year, yyyy. For example, 2001.

{symptoms:caption}
{symptoms:body}
{symptoms:validation}
{symptoms:description}
Does the client have:









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{seizuretypes:caption}
{seizuretypes:body}
{seizuretypes:validation}
{seizuretypes:description}
The power of Realm of Caring is creating community. If you are willing to be contacted by other families with the same or similar diagnosis, which contact information of yours may we share with them?

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{past:caption}
{past:body}
{past:validation}
{past:description}
{practitioner:caption}
{practitioner:body}
{practitioner:validation}
{practitioner:description}
{contact:caption}
{contact:body}
{contact:validation}
{contact:description}
{field:caption}
{field:body}
{field:validation}
{field:description}
{allergies:caption}
{allergies:body}
{allergies:validation}
{allergies:description}
{meds:caption}
{meds:body}
{meds:validation}
{meds:description}
Country*

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Street Address*

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Street Address 2

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City*

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State*

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{State:caption}*
{State:body}
{State:validation}
{State:description}
Zip Code / Postal Code*

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Phone Number*

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Phone Type*

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We may send occasional texts to inform you about RoC events or important happenings in the cannabis/hemp world. We strive to make these infrequent messages meaningful. By supplying your mobile number, you agree to accept text messages from RoC. Standard text rates may apply. Check the box below to opt-out.

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{mostvaluable:caption}
{mostvaluable:body}
{mostvaluable:validation}
{mostvaluable:description}
{interested:caption}
{interested:body}
{interested:validation}
{interested:description}
{interestedother:caption}
{interestedother:body}
{interestedother:validation}
{interestedother:description}
{donation:caption}
{donation:body}
{donation:validation}
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[widgetkit id=10]
  Advocate

Free

Advocate

Advocate

Benefactor

Benefactor

Sustainer

Sustainer

Visionary

Visionary

Monthly Contribution $0 $1 $10 $25 $50
Sustain Important Programs and Services  
RoC T-Shirt    
Quarterly Publication w/Coupons    
RoC Box      
Public Recognition        
VIP Access to RoC Events        
[grid]
Steward

Steward

$0 Monthly

 
  • Receive our newsletter to stay up-to-date with RoC news
Friend

Friend

$1 Monthly

Steward Benefits +
  • Website Portal Access
  • Care Specialist Consultations
Benefactor

Benefactor

$10 Monthly

Friend Benefits +
  • RoC Quarterly Publication w/exclusive coupons
  • RoC T-Shirt
Sustainer

Sustainer

$25 Monthly

Benefactor Benefits +
  • the RoC Box: great gear from RoC and our business supporters
[column size="1-5"] Visionary

Visionary

$50+ Monthly

Sustainer Benefits +
  • Public Recognition
  • VIP Access to RoC Events
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The Realm of Caring Foundation does not give or substitute for medical advice. It is important that you remain under a physician’s care.

Mutual Hold Harmless: Each party shall defend any third party claim against the other party arising from the death of or physical injury to any person or damage to the indemnified party's property to the extent proximately caused by the negligence of the indemnifying party or its agents or employees, and indemnify and hold harmless the other party and its respective officers, directors and employees from and against damages, liabilities and reasonable costs and expenses, including reasonable legal fees incurred in connection therewith.



Your privacy is one of our highest concerns. Please read through our Privacy Policy to understand how we collect and use your data.


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