BROOKLINE ADULT & COMMUNITY EDUCATION
SMARTSUMMERS/2008

EMERGENCY NOTIFICATION
CyberSummer Program
Session I (June 27-July 11) Session II (July 14-July 25) Session III (July 14-July 25)
Sessions I & II Sessions I & III Sessions II & III Sessions I, II & III

PRINT THIS FORM AND MAIL TO: BA&CE, P.O. Box 150, Brookline, MA 02446

Parents: Please complete and return this form as soon as possible (no later than May 23, 2008).

We do not require any additional physician’s medical forms.

If you would like to attach a photo of your child for our reference please do so.

Student's Name: ____________________________________________________________

Student’s Age: _________ Grade: ___________ Date of Birth: _____________Gender:_____

Address: ___________________________________________________________________

City: ______________________________ Zip Code: ____________________________

Parents’ Names: Parent 1: ___________________________/Parent 2:_____________________________

Home Telephone Number: _____________________________________/_______________________________

Work Phone Number:______________________________/______________________________________

Cell Phone Number: _____________________________/_______________________________________

E-Mail:__________________________________________/______________________________________

In Case of Emergency (if parents cannot be reached), please notify the following person:

Name: ______________________________________________________

Home Telephone Number: ____________________________________________________

Work Telephone Number: ___________________________________________________

 

MEDICAL INFORMATION

List any allergy, dietary, medical, or other special accommodations your child needs:

___________________________________________________________________________________

___________________________________________________________________________________

Pediatrician or Family Doctor: _________________________________________________

Doctor's Telephone Number: ______________________________________________________

Child's Insurance Plan Number (if any): ________________________________________

Name of Preferred Hospital: ____________________________________________________

PERMISSIONS (Optional)

I hereby give Brookline Adult & Community Education permission to release my child to walk home at the end of each day that he or she is enrolled in Brookline SmartSummers.

If not, list the adults who will be picking up the student:________________________________________

____________________________________________________________________________________________

I hereby give Brookline Adult & Community Education permission to photograph my child for publicity purposes while he or she participates in Brookline SmartSummers.

SWIMMING QUESTIONAIRE AND PERMISSION

Brookline SmartSummers Programs will be given the opportunity to walk to the Tappan Street pool and enjoy a free swim. In this case:

I give permission for my child to swim (please complete section below)
I do not give permission for my child to swim.

Children have the option of swimming in the big pool (deep water, lanes arranged for lap swimming), or in the children's pool, which is approximately 4 feet deep. If your child wishes to swim in the deep water, he or she will be asked to pass a standard swimming test: one lap of swimming on his/her back and one on his/her stomach. If your child has any special medical conditions related to participation in swimming, please tell us below:

________________________________________________________________________________

 

Parent's Name: _______________________________________________________________

Signature: _________________________________________Date: ______________________

 

This form must be returned by May 23, 2008

Mail to : BA&CE (SmartSummers), P.O. Box 150, Brookline, MA 02446