604-946-6622 info@reachchild.org

Reach Developmental Preschool Medical Information Form

    Family Doctor:


    Other Doctor 1 (i.e. Specialists):

    Other Doctor 2 (i.e. Specialists):

    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?



    (*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:*

    Tous les renseignements personnels fournis à Reach Child and Youth Development Society sont recueillis et utilisés conformément à la Personal Information Protection Act (PIPA) de la Colombie-Britannique. Pour plus de détails sur notre politique de confidentialité, veuillez nous contacter au 604-946-6622 ou par e-mail à info@reachchild.org

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