Summer Discovery Programs Medical Form
Due no later than June 1st
Roaring Brook Nature Center
70 Gracey Road, Canton, CT 06019
PLEASE NOTE: We will accept a medical form from your doctor that is current withing the last 36 months.
HOWEVER, WE ALSO NEED A COPY OF THE FORM BELOW SIGNED BY A PARENT!!
If your child has any special needs we request that you notify staff prior to the first day of class!
_________________________ has no physical or medical conditions that will limit full participation
child's name in summer program activities at Roaring Brook Nature Center.
Bee sting or other allergies?___________________________________________________________
Is he/she taking any prescription medication? Yes________ No________
If yes, please inticate prescription: _________________________________________________
NOTE: Epi-pens MUST come with authorization form from doctor - check RBNC office)
This camper is up-to-date on all the following routine childhood immunizations currently recommended:
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
Classed attending & dates:___________________________________ _______________________
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