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.

    Make checks payable to
    "Reach Program."

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

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