RBNC Summer Discover Days Medical Form
Due June 15
Please send with registration and payment to:
Roaring Brook Nature Center
70 Gracey Road, Canton, CT 06019

PLEASE NOTE: We will accept a medical form from your doctor that is current (within 36 months). HOWEVER, WE ALSO NEED A COPY OF THE FORM BELOW SIGNED BY A PARENT!!

 
___________________________________ (child's name) has no physical or medical conditions that will limit full participation in summer program activities at Roaring Brook Nature Center.
Bee sting or other allergies?    Yes     No   (circle)
     If yes, please describe:______________________________________________________

Is he/she taking any prescription medication?     Yes       No     (circle)
     If yes, please list:___________________________________________________________  
     NOTE: Epi-pens MUST come with authorization form from doctor - check with RBNC office)

Does your child have any special needs?____________________________________________
                                                                                                                                   (Please use back of form if needed)
        If your child has any special needs we request that you discuss with staff prior to first day of class!

Is he/she up-to-date on all the following routine childhood immunizations currently recommended (please check):
Yes
No
 
Yes
 
No
   
Yes
 
No
Measels ____ ____   Hepatitis B ____ ____   Chickenpox ____ ____
Mumps ____ ____   Diptheria ____ ____   Polio ____ ____
Rubella ____ ____   Pertussis ____ ____   Tetanus ____   ____
Date of last exam: _________________________________
Child's Physician: _________________________________ Phone:___________________
PERSON TO BE CONTACTED IN CASE OF EMERGENCY (REQUIRED INFORMATION):
___________________________________________ PHONE #:____________________
In case of a serious medical emergency, Roaring Brook Nature Center has my permission to obtain emergency servies (911).
_________________________________________    _______________________ 
            Signature of Parent or Guardian                                                                       Date
Classes Attending: __________________________________ Date: __________________
  __________________________________   __________________
  __________________________________   __________________
:

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