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Form Pps-F004 - Affidavit Of Residency For Purposes Of Obtaining School Accommodations Page 2

If (b), PLEASE INDICATE ONE OF THE FOLLOWING:

(1) I have provided emergency contact information for myself to the Milford Public Schools and I am the only

person with authority to make educational and/or medical decisions on behalf of the above-named

child(ren); or

(2) I have provided legal documentation to the Milford Public Schools indicating that in my absence, the

following person has legal guardianship of my child(ren) and may be contacted to make educational and/or

medical decisions regarding the above-named child(ren):

Name: ___________________________________________

Address: _________________________________________________

Telephone Number(s): _________________________________________________________________

Signed and sworn before me this _____ day of ______________, ___________.

____________________________________

_________________

Signature

Date

STATE OF CONNECTICUT

)

) SS

COUNTY OF

)

Personally appeared, ________________________________, and made oath to the truth of the foregoing

statement.

_______________________________________

Notary Public

My commission expires _________________________.

Date: 11/01/2006, Revision B

DOC #PPS-F004

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Form Pps-F004 - Affidavit Of Residency For Purposes Of Obtaining School Accommodations Page 2