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Medical Forms

* indicates a required answer.

Please fill this out once for each child participating in a ReACHE activity.

1. *

Child's name

2. *

Parent's Name and Phone Number

3. *

Allergies (Food, Insects, etc.):

4. 

How to Treat:

5. 

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. 

6. *

Child's Doctor's Name and Phone Number:

7. *

Emergency Contact Name & Phone Number

8. 

2nd Emergency Contact Name and Phone Number (if applicable)

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