Excursions in Learning
Health and Safety 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
Mother/Guardian Name Phone Number(s)
Father/Guardian Name Phone Number(s)
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?
n
Yes
n
No
Date of last medical exam:
Physician’s name and practice address/phone:
ADDITIONAL EMERGENCY CONTACTS
If parents/guardians unreachable:
Full Name
Full Name
Relationship to Child
Relationship to Child
Phone Number(s)
Phone Number(s)
AUTHORIZED PICK-UP IN ADDITION TO PARENTS
In addition to the parents/guardians listed above, what other adults are authorized to pick up your child from Excursions in Learning? (They must show a photo ID to pick up your child.)
Full Name
Full Name
Relationship to Child
Relationship to Child
Phone Number(s)
Phone Number(s)
PHOTO RELEASE AND CONSENT REQUIRED
In the unlikely event that reasonable attempts to contact the child’s parents/guardians and emergency contacts have been unsuccessful, I hereby give my consent for the Excursions in
Learning nurse to arrange for emergency transportation and/or care.
As part of our ongoing effort to promote the program, we may take photographs and video of children involved in learning activities. Do we have permission to photograph/film your child and
place said photos/videos in advertisements, our catalog, our Facebook page and website? Names will not be used.
n
Yes
n
No
Parent/Guardian Printed Name
Signature
Date
January 2020/PR
