Student Contact Verification Form
Changes to the current contact information that we have on record can be made by completing the information below.

ADDRESS CHANGES CANNOT BE COMPLETED ON THIS FORM! You must bring residency verification to Central Registration at Mattituck Jr/Sr High School.

Please contact the school health office annually to update your child's health history. This include any NEW medications, diseases, allergies, injuries, surgeries and/or medical conditions.

Update only the fields you would like changed.
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Student's First name *
Student's Last Name *
Updated Home Phone Number
Father's First Name
Father's Last Name
Father's Home Phone # (if different)
Father's Cell Phone #
Father's Work Number
Father's Email Address
Mother's First Name
Mother's Last Name
Mother's Home Number (if different)
Mother's Cell Phone #
Mother's Work Number
Emergency contact (first and last name)
Emergency contact home telephone number:
Emergency contact cell phone number:
Emergency contact work telephone number:
Relationship to student:
Any additional information you feel the district should be aware of? (Please contact the Health Office with any medical information)
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