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!!
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| ___________________________________ (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)
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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!
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Is he/she up-to-date on all the following routine childhood immunizations currently recommended (please check):
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Yes |
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No |
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Yes |
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No |
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Yes |
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No |
| Measels |
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____ |
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Hepatitis B |
____ |
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____ |
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Chickenpox |
____ |
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____ |
| Mumps |
____ |
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____ |
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Diptheria |
____ |
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____ |
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Polio |
____ |
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____ |
| Rubella |
____ |
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____ |
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Pertussis |
____ |
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____ |
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Tetanus |
____ |
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____ |
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| 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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