REACH Enrollment Form

Your Child's Health Information
Family Doctor*
Phone Number*
Please enter a valid phone number.
Family Dentist
Phone Number
Please enter a valid phone number.
Medications. Please list prescription medications and dosages. Please not a physicians health form and physical are required for enrollment. All medications and allergies should be listed on that form. If none, please put NA.*
Please list known allergies. Must be documented by a physician. If none, please put NA *
REACH Early Learning has my permission to apply preventive products such as sunscreen and insect repellant on my child.*

YesNoOther

Social and Emotional Development
Has you child been in childcare before?*

YesNo
Who typically cares for your child when you are away?*
How would you describe your child's personality?*
Does you family have pets? Please describe.*
Is there anything we should know about your child's play with other children or by themselves?*
What events had the greatest impact on your child? (ie moving, births, deaths, severe illness of family members, divorce)*
What are your expectations or hopes for your child at REACH?*

Authorized Pick Up List

Identification will be required
All Students must have alternative Emergency Contacts, other than Parents/Guardians listed above, to ensure contacted with an approved source if the above mentioned are not able to be reached in an emergency.
Contact Person 3

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Contact in case of emergency

YesNo
Relationship to Child
Contact Person 4

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Contact in case of emergency

YesNo
Relationship to Child

REACH Early Learning Enrollment Packet