Household members
+ Add adult + Add child Phone number *
Phone type Mobile Home Work Other
Gender *
Select… Male Female
Grade *
Select… Pre-K Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Medication prescribed to your child by doctor *
Is your child able to communicate verbally? *
What language does you child understand? *
Does your child eat solid food? *
Please list any dietary restrictions your child has, including any food, medical and other allergies. *
Include allergies and snack time preference
Is your child in school? *
Behavioral Information *
Check all that apply
Are you okay with your child entering age appropriate class with buddy? *
If your champion is able to, they may attend age appropriate (either grade or comprehension level) with an adult buddy.
Are you okay with having your child's photo being taken and share on Rez social media? *
If no, if there was a group picture taken, are you okay with your child's face being covered with a sticker? *
Please note any additional information that would help us to provide the best care for your child: *
Include any questions/ concerns/ additional comments
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