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MASHPEE PUBLIC SCHOOLS PERSONAL DATA/EMERGENCY INFORMATION <br /> STUDENT NAME: GRADE/TEACHER D.O.B. <br /> SOCIAL SECURITY# HOME PHONE <br /> HOME ADDRESS CELL PHONE <br /> MAILING ADDRESS E-MAIL ADDRESS <br /> Legal Guardian is Mother Father _Both Other <br /> Resides with Mother _Father _Both Other <br /> Where can parent/legal guardian be reached if not at home? <br /> Mother/Guardian Name Work Phone Cell Phone <br /> Father/Guardian Name Work Phone Cell Phone <br /> List two neighbors or local relatives who will assume temporary care of your child if you can not be reached. <br /> 1. Name Relationship to child <br /> Address Telephone <br /> 2.Name Relationship to child <br /> Address Telephone <br /> Please use back of this form if your student has any custodial issues that we should be made aware of. <br /> MEDICAL INFORMATION: <br /> Does your child have any health conditions? —Yes —No <br /> If yes,please specify: <br /> Asthma —Bee Sting Allergies _Wears Hearing Aid _Allergies _Medicine <br /> _Kidney/Bladder _Intestinal Irregularities _Blind _Deaf <br /> Arthritis Seizures _Speech Difficulty _Heart <br /> Other(specify) <br /> Physical Handicap(describe) <br /> Medicine at Home: No Yes: <br /> Medicine at School: _No _Yes: <br /> Physician's Name: Telephone <br /> Dentist's Name: Telephone <br /> In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby <br /> authorize school authorities to exercise their judgment in calling the physician indicated above and to follow his/het <br /> instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary (tc <br /> transport the child to the local emergency department). <br /> Signature of Parent/Legal Guardian: Date <br /> Does your child have Health Insurance? —No —Yes Dental Insurance? —No —Yes <br /> Health Insurance Company Policy Number: <br /> If you have no health insurance,Massachusetts has health insurance plans that will provide uninsured children with affordable health <br /> care. (restrictions may apply)Please contact the school nurse for more information about these programs.All communications will be <br /> confidential. I authorize K.C. Coombs School Nurse's Office to share pertinent medical information with my child's teachers and <br /> appropriate staff. <br /> Signature of Parent/Legal Guardian: Date <br /> SPECIAL NOTE: Please notify school officials IMMEDIATELY to changes or modifications to any/all information stated above. <br /> 63 <br />