Excursions in Learning
Health Supplemental Form
To be completed by the student’s parent or guardian and returned to Linda Armstrong, Excursions in Learning,MS #16, Manchester Community College, P.O. Box 1046, Manchester, CT 06045-1046;
or fax form to 860-512-2801; or scan form and attached to email and send to larmstrong@manchestercc.edu.
STUDENT INFORMATION
Child’s First Name MI Last Name Date of Birth
Street Address Apt. #
City State Zip
Parent/Guardian Name Relationship to Child
Home Phone Cell Phone Email
Additional Parent/Guardian Name Relationship to Child
Home Phone Cell Phone Email
STUDENT HEALTH INFORMATION
List and explain any allergies:
List any health conditions:
List all medications and dosages:
(If EpiPen, Benadryl®, inhaler or other medications may need to be administered during the Excursions program, please ask your child’s pediatrician for a signed medical authorization form
and submit to Linda Armstrong, Excursions in Learning Coordinator.)
If your child receives any additional accommodations at their school, please explain:
Would you like the nurse to contact you before the program starts? (TAG Academy and Tech/Steam programs only)
n
Yes
n
No
Date of last medical exam: Physician’s Name and Practice
Physician’s Phone
Parent/Guardian Printed Name
Signature
Date
December 2019/PR
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