Please print all information and complete all the blanks.

Name_______________________________________Date of Birth________________

(Last) (First)

Age____________ Sex____________ Weight____________ Height_____________

Address________________________________________________________________

(Street and No.) (Town) (State) (Zip)

Parent/Guardian_________________________________________________________

Home Telephone(____)_______________Work Telephone(_____)________________

Please list LOCAL friends and relatives, who have your permission to transport your child if necessary.

Name Address Phone #

Family Physician________________________ Telephone(____)________________

I give permission for (Name)___________________________ to attend Nature’s Classroom

for the period of ____________________________ as part of the outdoors Education

Program of Helen Keller Middle School. I understand that the Director of

Nature’s Classroom may, if necessary for my child’s health, have him/her

hospitalized or use outside medical, surgical or dental care. I also authorize the

administration of routine first aide treatment for minor injuries not requiring a

physician’s attention. I also understand that the director and/or school leaders may

dismiss my child from Nature’s Classroom if, in their opinion, his/her conduct or

influence is not in the best interest of the entire group. No refund is given if such

action is taken for discipline reasons.

_____________________________________ ________________________