School Nurse Emergency Card 2021-2022
Please submit this information yearly for each of your ECDC Students so the School Nurse will have your most current contact information, alternate emergency contacts, and a list of your student's health issues. If this form cannot accommodate the amount of information you need to disclose to the school nurse, Miss Suzanne Roma ,  please call her at (508)-541-8166 . Once you click "submit" you will receive a confirmation that we received your submission of this form.
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Email *
Your Student's First Name *
please use legal name, no nicknames
Student Middle Name *
Use full middle name, no initials; If no middle name, type "NMN"
Student Last Name *
Student Date of Birth *
mm/dd/yyyy
Student Address that they share with Parent/Guardian#1
If this address is different from the one we have on file for you and your student in Aspen, you are required to complete a CHANGE of ADDRESS online form HERE: http://docs.google.com/forms/d/e/1FAIpQLSeWHGc78HpXdBoTN8DSES-xM_Bt07jUPEA1D-xulAaopk9qbg/viewform
Student's Street Address *
Parent/Guardian#1 Full Name *
This parent lives with the student; please list full name
Parent/Guardian #1 relationship to student *
Parent/Guardian#1 Email address *
if no email address type "NONE"; This may be the same as the one you listed above.
Parent/Guardian#1 best contact Phone Number *
Is this Parent/Guardian#1's home, mobile, or work phone? *
Does Parent/Guardian #1 have any other phone numbers they wish to share?
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