Health And Emergency Contact

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Arlington Public Schools: Student Registration
SASID #
(official use only)
869 Massachusetts Avenue, Arlington, MA 02476 | arlington.k12.ma.us
Last Name
First Name
Middle Name
District of Residence
Date of Pre-Reg.
Health and Emergency Contact
Student's Personal Information
Physical Address
City
Mailing Address
Home/Primary Phone #
Gender
Current Grade
Date of Birth
Place of Birth , ,
Health Information
Yes
No
Have health insurance?
Name of Company
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
communication is confidential.
Physician's Name
Phone
Dentist's Name
Phone
Hospital of Choice
ADD / ADHD
Autism / Asperger
Diabetes Type 1
Migraines
List all conditions
Allergies
Depression
Diabetes Type 2
Seizure Disorder
that apply
Asthma
Development Delay
Heart Condition
Yes
No
List all Allergens
Have an EpiPen?
Yes
No
Yes
No
Hearing problems?
Vision problems?
Describe
Describe
(1) Parent / Guardian
Title and Name
Home Address
Phone 1
Phone 2
Email
(2) Parent / Guardian
Title and Name
Home Address
Phone 1
Phone 2
Email
Yes
No
I give my permission to the school nurse to:administer Acetaminophen / Ibuprofen to my child.
I give permission to the school nurse to share information relevant to my child’s health condition with appropriate
Yes
No
school personnel when needed to meet my child’s health and safety needs and to exchange information with my
child’s physician/counselor for the purpose of referral, diagnosis and treatment.
Print Name
Signature
Date
4 of 8
This form can be downloaded from (revised 2/13/2013)

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