EASTON PUBLIC SCHOOLS – STUDENT EMERGENCY INFORMATION

Legal Last Name: / First: / Middle: / Gender: / r M r F
Date of Birth: / LASID: / SASID: / GR: / YOG:
Address: / Preferred Phone:
Home Language: / HR: / School:

1st Person to be Contacted Current Information Corrections

Name:
Relationship:
Address:
City, State, Zip:
Home Phone:
Cell Phone:
Work Phone (with Extension):
Email:
Contact lives with student r

2nd Person to be Contacted Current Information Corrections

Name:
Relationship:
Address:
City, State, Zip:
Home Phone:
Cell Phone:
Work Phone (with Extension):
Email:
Contact lives with student r / r This is a non-custodial parent that requires duplicate school communications

Names of other parties who are aware and readily available to assume responsibility/transportation of your child:

3rd Person to be Contacted Current Information Corrections

Name:
Relationship:
r Home Phone:
r Cell Phone:
r Work Phone

4th Person to be Contacted Current Information Corrections

Name:
Relationship:
r Home Phone:
r Cell Phone:
r Work Phone
Child resides with: Both Parents r Mother r Father r Guardian/Other r: ______
Please indicate if there are any parental restrictions (e.g. current restraining order – must be on file in school office):
r No Changes / Parent/Guardian Signature: / Date:


OTHER INFORMATION

Legal Last Name: / First: / Middle: / Gender: / r M r F
Date of Birth: / LASID: / SASID: / GR: / YOG:
Address: / Preferred Phone:
Home Language: / HR: / School:
Hispanic: / r Yes r No / Race:

MEDICAL

Allergies or health problems that we need to know about your child:
Primary Health Care Provider: / Phone No.:
Name of Dentist: / Phone No.:
Health Insurance: / r Yes r No / Health Insurance Company: / Policy #

If you have no health insurance, Massachusetts has health insurance plans that will provide uninsured children with affordable health insurance (restrictions may apply). If you are interested in more information about these programs, please contact the School Nurse.

r  I give permission to the School Nurse to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my child’s health and safety needs. I give permission to exchange information with my child’s primary care provider and/or emergency personnel for the purpose of referral, diagnosis and treatment. I understand in the event of a medical emergency my child may be transported to the nearest local hospital by ambulance.

I will not hold the school district financially responsible for the emergency care and/or transportation for said child.

Parent/Guardian Signature: / Date:

PERMISSIONS AND CONSENTS

r YES, the Easton Schools have my permission to use my child’s image for newspapers/print, TV/video and website/Internet.

r  YES, the Easton Schools have my permission to use my child’s school work for newspapers/print, TV/video and website/Internet.

r  NO, I prefer that my child’s image and/or school work (please circle one or both) not be recorded or displayed for public presentation in any form. I do not give my permission.

Parent/Guardian Signature: / Date:

HANDBOOK

r  I have received, read and understand the student family handbook and I am aware that the electronic version of the student handbook as available on the website is the most current version and will contain any updates and amendments.

Parent/Guardian Signature: / Date:

INTERNET POLICY

r  I have received, read, understand and agree to follow the district’s internet acceptable use policy.

Parent/Guardian Signature: / Date:

4/10/2012 12:58 PM