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?

OuiNon
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*:OuiNon
Date:

Hearing*:OuiNon
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:*

_{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}