Home State Health

Want to become part of Homer’s Kids Club? Have your parent/guardian sign you up. Once signed up, you will get a book and Homer's Kids Club ID card sent to you at no cost.

You must be 18 years or older to fill out this form.

Open to Missouri residents ages 10 and under.

Fields marked with a "*" are required.

Email Address*

Child's First Name*

Child's Last Name*

Child's Age*

Child's Date of Birth*

How did you learn about Homer’s Kids Club?*

Are you a Home State Health or Show Me Healthy Kids member?*

Yes

Parent/Guardian's First Name*

Parent/Guardian's Last Name*

Street Address*

City*

State / Province*

PostalCode*

Phone number*

Please enter a 10 digit phone number with no special characters.

By submitting this form, you are consenting to receive marketing emails from: Home State Health, 7711 Carondelet Ave, St. Louis, MO 63105, United States, https://www.homestatehealth.com/
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