Person completing form:
Email address:
Child's Name:
Please list any medical problems; i.e. diabetes, asthma, epilepsy, allergies, medical allergies, and any other information you feel would be helpful to our staff to enable them to better serve you and your child: Please list any medication: Please list any special needs, i.e. attention deficit, hearing or visual impairment, hyperactivity: PARENTAL PERMISSION In the event of an emergency during which we cannot be reached we hereby give permission to the bearer of this form to allow any doctor or medical facility to administer an anesthetic and perform emergency procedures as may be necessary for our child child's name. I will not hold the officials or agents thereof, financially responsible for whatever emergency care may be provided. Physician’s Name:Phone: Hospital Preference: We understand and agree that the Rocky Hill Parks & Recreation Department reserves the right to suspend a child from a Parks & Recreation sponsored activity if that child displays a serious behavior problem that cannot be effectively managed by the program personnel. Parent/Participant Signature Date