Summer Discovery Programs Medical Form

Due no later than June 1st

Send 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 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:

Yes
No
 
Yes
No
Measels Hepatitis B
Mumps Diptheria
Rubella Pertussis
Chickenpox Polio
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

Classed attending & dates:___________________________________   _______________________

                                      ___________________________________   _______________________

                                      ___________________________________   _______________________

 

 

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