Reach Developmental Preschool Medical Information Form

Family Doctor:

Family Doctor Phone #:

Family Doctor Address:

Pediatrician:

Pediatrician Phone #:

Pediatrician Address:

Other Doctor 1 (i.e. Specialists):

Doctor Phone #:

Doctor Address:

Other Doctor 2 (i.e. Specialists):

Doctor Phone #:

Doctor Address:

Does your child have any allergies?

YesNo
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?

Does your child have any formal diagnosis?

Has your child had either of the following tests?

Vision*:YesNo
Date:

Hearing*:YesNo
Date:

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 [email protected]}