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2008-2009 MASHPEE PUBLIC SCHOOLS PERSONAL DATA/EMERGENCY INFORMATION STUDENT NAME: GRADE/TEACHER D.O.B. SOCIAL SECURITY# HOME PHONE HOME ADDRESS CELLPHONE MAILING ADDRESS E-MAIL ADDRESS Legal Guardian is Mother _Father _Both Other Resides with Mother Father Both Other Where can parent/legal guardian be reached if not at home? Mother/Guardian Name Work Phone Cell Phone Father/Guardian Name Work Phone Cell Phone List two neighbors or local relatives who will assume temporary care of your child if you can not be reached. 1.Name Relationship to child Address Telephone 2.Name Relationship to child Address Telephone Please use back of this form if your student has any custodial issues that we should be made aware of. MEDICAL INFORMATION: Does your child have any health conditions? Yes —No - If yes,please specify: Asthma _Bee Sting Allergies Wears Hearing Aid _Allergies _Medicine _Kidney/Bladder _Intestinal Irregularities _Blind _Deaf Arthritis _Seizures _Speech Difficulty _Heart Other(specify) Physical Handicap(describe) Medicine at Home: No Yes: Medicine at School: No Yes: Physician's Name: Telephone Dentist's Name: Telephone In case of accident or serious illness,I request the school to contact me.If the school is unable to reach me,I hereby authorize school authorities to exercise their judgment in calling the physician indicated above and to follow his/her instructions.If it is impossible to contact this physician, the school may make whatever arrangements seem necessary(to transport the child to the local emergency department). Signature of Parent/Legal Guardian: Date Does your child have Health Insurance? _No _Yes Dental Insurance? —No —Yes Health Insurance Company Policy Number: If you have no health insurance,Massachusetts has health insurance plans that will provide uninsured children with affordable health care. (restrictions may apply)Please contact the school nurse for more information about these programs.All communications will be confidential. I authorize K.C.Coombs School Nurse's Office to share pertinent medical information with my child's teachers and appropriate staff. Signature of Parent/Legal Guardian: Date SPECIAL NOTE: Please notify school officials IMMEDIATELY to changes or modifications to any/all information stated above. 63