Deer Isle-Stonington Elementary Emergency Contact Form
Email address
Student Name
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Birthdate
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Gender
Current grade for 2017-2018 School Year
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Parent 1 Name
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Parent 1 Residence Address
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Parent 1 Mailing Address
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Parent 1 Home Phone#
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Parent 1 Cell Phone #
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Parent 1 Work Phone #
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Parent 1 Email Address
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Parent 1 Place of Employment
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Parent 2 Name
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Parent 2 Residence Address
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Parent 2 Mailing Address
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Parent 2 Home Phone #
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Parent 2 Cell Phone #
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Parent 2 Work Phone #
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Parent 2 Place of Employment
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Parent 2 Email Address
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Emergency Contact #1- Name
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Emergency Contact #1 Phone #
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Emergency Contact #1 Relationship
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Emergency Contact #2 Name
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Emergency Contact # 2 Phone #
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Emergency Contact #2 Relationship
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Emergency Contact #3 Name
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Emergency Contact #3 Phone #
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Emergency Contact #3 Relationship
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Medical Information/ Allergies/ Other Conditions/Remarks:
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Physician Name and Phone #
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