MEDICAL RELEASE FORM

Should an accident or illness occur, it may be necessary to provide for local emergency medical service for clients participating in any therapy services at the REACH Program. Please indicate your permission for such treatment by completing and signing the form below.

In case of emergency, the REACH Program is authorized to call 911 for emergency services. If it should be necessary for an ambulance to be obtained, I will assume payment of such a bill.

Physician Information:

In case of an emergency, please contact:

CONTACT US

Cubberley Community Center
Building P
4000 Middlefield Road,
Palo Alto
Phone: (650)-690-5615    
reachprogrampaloalto@gmail.com

SUPPORT

Help enable us to provide our services; 100% of any donation goes to REACH.

Use this Paypal link to donate any amount you wish or
Make checks payable to
"Reach Program."

Send to:
REACH Program
4000 Middlefield Road,
Palo Alto CA 94303

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