Inclusion Questionnaire Basic Information Thank you for completing the Reach inclusion questionnaire. All disclosures are optional. OK Question Title * 1. Today's Date Date Date OK Question Title * 2. Participant's Name OK Question Title * 3. Date of Birth Date Date OK Question Title * 4. Address Address City State ZIP OK Question Title * 5. Phone Number OK Question Title * 6. Current grade in school (if applicable) OK Question Title * 7. Caregiver's Names OK Question Title * 8. Caregiver's Phone Numbers Home Work/Cell OK Question Title * 9. Caregiver's Email(s) OK Question Title * 10. Siblings Names/Ages (if applicable) OK Question Title * 11. Emergency Contact Name Relationship Phone Number OK Question Title * 12. Are you familiar with other Reach programs? Please check all that apply Adaptive Recreation Community Living Support & Employment Services Mental Health Services Case Management None of the above OK Question Title * 13. Would you like to be added to the Reach mailing list? (check all that apply) Email Mail No thanks OK NEXT