Teen REACH Re-Enrollment 2020-2021
Sesser-Valier Teen REACH is receiving funding for the next year (July 1, 2020 – June 30,
2021). Since your child is currently enrolled in the Teen REACH program, we are asking that
he/she re-enrolls.

By completing the information below, you are granting permission for your child’s re-enrollment. By typing your name at the bottom of this form you are giving your consent for field trips, photography releases, and for outcome measurements to be put into DHS’s eCornerstone.

You will notify the staff of any changes in your child’s medical condition, medications, or risk factors.
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Email *
Student Name *
Street Address *
City, State and Zip Code *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Grade for the 2020-2021 School Year *
Emergency Contact Name and Number 1 *
Emergency Contact Name and Number 2 *
Parent Name *
Parent/Guardian Phone Number *
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