Inclusion Questionnaire

Basic Information

Thank you for completing the Reach inclusion questionnaire.

All disclosures are optional.

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* 1. Today's Date

Date

Date

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* 2. Participant's Name

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* 3. Date of Birth

Date

Date

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* 4. Address

Address

City

State

ZIP

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* 5. Phone Number

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* 6. Current grade in school (if applicable)

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* 7. Caregiver's Names

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* 8. Caregiver's Phone Numbers

Home

Work/Cell

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* 9. Caregiver's Email(s)

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* 10. Siblings Names/Ages (if applicable)

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* 11. Emergency Contact

Name

Relationship

Phone Number

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* 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

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* 13. Would you like to be added to the Reach mailing list? (check all that apply)

Email

Mail

No thanks