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MATRÍCULA Bronce I
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registrations@reachacademy.nyc

Special Needs Intake Form

NOMBRE Y APELLIDO DEL PADRE

PARENTS CELL PHONE NUMBER (number we can send text)

CORREO ELECTRÓNICO DEL PADRE PRINCIPAL

NOMBRE Y APELLIDO DEL NIÑO (O NIÑOS)

CHILD'S DATE OF BIRTH

EDAD DEL NIÑO (O NIÑOS)

WHAT IS THE LEVEL OF DIAGNOSIS FOR YOUR CHILD

IS YOUR CHILD VERBAL

HOW WELL DOES YOUR CHILD FOCUS IN CLASS SEETTINGS

WHAT IS YOUR CHILD'S COMFORT WITH THE WATER

DOES YOUR CHILD HAVE ANY FEARS OF WATER OR EXTREME SENSORY ISSUES (PLEASE EXPLAIN)

PLEASE PROVIDE US WITH ANY PERTINENT INFORMATION THAT WILL HELP US

HOW DID YOU HEAR ABOUT US?

¡Gracias por enviar!

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