Lakeshore Middle School Emergency Contact Information
13.5 Task 2 Assessment
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CACE ESL Student & Class Information
CACE ESL Student Name *
CACE ESL Class *
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Use the personal history paragraph to complete the form below.
Lakeshore Middle School Student Information
Lakeshore MS Student's First and Last Name
Student's Primary Address
Student's Cell Phone Number
Parent Information
Please provide the most current contact information for the student's parent.
Mother's First and Last Name
Father's First and Last Name
Parent's Address
Mother's Cell Phone Number
Father's Cell Phone Number
Home Phone Number
Mother's Work Phone Number
Father's Work Phone Number
Mother's Email
Father's Email
Emergency Contact #1 Information
In the event of an emergency we will contact this person first.
First and Last Name
Relationship
Cell Phone Number
Work Phone Number
Home Phone Number
Address
Email
Emergency Contact #2 Information
In the event that emergency contact #1 cannot be reached we will contact this person.
First and Last Name
Relationship
Cell Phone Number
Work Phone Number
Home Phone Number
Address
Email
Medical Contact Information
Please provide the most current medical contact information.
Primary Physician Name
What type of facility does the physician use for medical appointments?
Clear selection
Physician Phone Number
Physician Address
Medical Plan Provider
Clear selection
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