604-946-6622 info@reachchild.org

Reach Developmental Preschool Medical Information Form




Does your child have any allergies?


If yes, please list and provide additional information including reactions and treatment:

Does your child have any dietary requirements, medical needs, and or take medication?


If yes, please specify:

Does your child have any formal diagnosis?


If yes, please provide additional information

What other services, if any, is your child currently receiving?


Has your child had either of the following tests?

Vision*:
Date:
Hearing*:
Date:

(*Please email a copy of your child’s immunization to alexandrav@reachchild.org)

The information I have provided in this form is current as of the date listed below. Should any information change, I will advise the Reach Developmental Preschool-South Delta as soon as possible.

Parent(s) / Guardian(s) Signature:*


Any personal information provided to Reach Child and Youth Development Society is collected and used in accordance with British Columbia’s Personal Information Protection Act (PIPA). For details of our privacy policy, please contact us at 604-946-6622, or email info@reachchild.org

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