Caution: uncheck this box if you are on a public computer (i.e. Hotel, Coffee Shop)
* indicates a required answer.
Please fill this out once for each child participating in a ReACHE activity.
Parent's Name and Phone Number
Allergies (Food, Insects, etc.):
How to Treat:
Our co-op teachers want to do everything they can to ensure your child has a pleasant experience in class. Please provide any information that may be helpful for the teacher to know in a classroom situation (i.e. social anxieties, learning disabilities, etc). This information will only be shared with those working directly with your child in a capacity that would be affected by his/her special needs.
Child's Doctor's Name and Phone Number:
Emergency Contact Name & Phone Number
2nd Emergency Contact Name and Phone Number (if applicable)