What do I need to register my child?

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Student Registra on Requirements

Family Resource Center

31 West Fountain Street 508-478-1135 x 4603 - Phone Milford, MA 01757 508-473-1601 - Fax www.milfordpublicschools.com FRC@milfordma.com

The FRC is open for Student Registra on Monday - Friday 9am to 3pm and is located at Milford High School; DO NOT GO IN THE FRONT DOOR OF THE HIGH SCHOOL.

From West Fountain Street, drive down the le side of the High School to the last parking lot on the le . Ring the doorbell on the le side of door 19A and enter.

What do I need to register my child?

1. COMPLETED ENROLLMENT PACKET

2. SCHOOL RECORDS: It is the parent’s responsibility to provide copies of student's Report Card , IEP, 504, ACCESS for EL scores, MCAS scores, etc.

3. BIRTH CERTIFICATE (or passport): A copy of your child’s birth cer ﬁcate or passport is required for

all new (and returning) students. PROOF OF GUARDIANSHIP is also required if child is not living

with one or both parents listed on birth cer ﬁcate.

4. MOST RECENT PHYSICAL EXAM : A physical examina on from your child's health care provider's

oﬃce or clinic is required for all new (and returning) students. The physical date must be within

the last 12 months. For KINDERGARTEN students, the following are also required: 1) LEAD

screening date & results, and 2) VISION screening date & results.

5. PROOF OF IMMUNIZATIONS : Milford Public Schools follows all Massachuse s requirements for

immuniza ons. (Massachuse s Department of Public Health h p://www.mass.gov/dph)

6. TUBERCULOSIS RISK ASSESSMENT FORM : The a ached assessment form must be completed and

signed by your child's health care provider.

7. ANNUAL STUDENT HEALTH UPDATE CARD : Completed on both sides.

8. RESIDENT CARD from MILFORD TOWN HALL : A Milford resident card is required for all new (and

returning) students. To obtain a Milford resident card you must go to the Town Clerk’s oﬃce at the Town Hall, 52 Main Street.

* A homeowner must bring to Town Hall:

1. their Purchase & Sales Agreement OR a copy of their Field Card from the Assessor’s Oﬃce, 2. the AFFIDAVIT OF RESIDENCY form (included in this enrollment packet), and

3. a photo ID

- - - -- - - * A renter must bring to Town Hall:

1. EITHER a copy of the LEASE ( only if lease lists names of all adults and children - If not, you are required to obtain a notarized le er (see below)).

OR a notarized le er from landlord/rental agent sta ng: - the address,

- names and dates of birth of all adults and children living in the home, - the landlord’s contact phone number and address.

2. the AFFIDAVIT OF RESIDENCY form (included in this enrollment packet) signed by the landlord/rental agent (demonstra ng Housing Bylaw compliance) ; and

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Student Registra on Requirements

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

Upon school enrollment, the following

medical documenta on and immuniza ons

are required for all students:

Most recent physical (within 12 months)

Immuniza ons Grades K - 12:

5 doses of DTaP vaccine

4 doses of polio vaccine

2 doses of MMR vaccine

3 doses of hepa s B vaccine

2 doses of varicella vaccine

or a Physician-cer ﬁed reliable history of chicken pox disease

1 dose of Tdap (7th - 12th grade only)

Tuberculosis Risk Assessment Form (a ached, completed by health care provider)

Lead Screening (date and results - Kindergarten only)

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Student Registra on Requirements

___ Brookside Elementary School (Grades K, 1 & 2) ___ Stacy Middle School (Grades 6, 7 & 8)

___ Memorial Elementary School (Grades K, 1 & 2) ___ Milford High School (Grades 9,10,11,&12) ___ Woodland Elementary School (Grades 3, 4 & 5)

for oﬃce use only:

EL Status: EL ﬂuent =NOT EL WIDA Screener/ACCESS Comp Level ______

Today's Date: _____/______/20______ Last Completed Grade: ______ Current Grade: __________ YOG: ___________ Student’s Name: ___________________________________________________________________________________

Last Name First Name Middle Name

Date of Birth: _______/ _____/20_______ Gender: Male

❐

Female

❐

Non-binary

❐

Month / Day / Year

Student’s Home Address: _____________________________________________________________________________ Phone (call 1st): _________________________________ circle: HOME CELL WORK U.S. Military Parent or Guardian?_______

(ac ve duty, med discharge or re red w/in yr, widowed/ac ve duty)

Student's Place of Birth: _____________________________________________________________________________ City State Country

Child Lives With: _____________________________________ Siblings in Milford Schools? Yes ❐ No ❐ For your child’s safety, is there any legal paperwork that the school should have copies of? Yes ❐ No ❐ Who has legal custody of the child? ___________________________________

My student receives services: ❐ IEP ❐ 504 ❐EL ❐FEL ❐ Math Interven on ❐ Reading Interven on

1) Parent/Guardian’s Name : ___________________________________________

Phone (call 2nd):__________________ circle: HOME CELL WORK | Phone (call 3rd):_________________ circle: HOME CELL WORK Speaks English? Yes _____ If No, Language _________________ Country of Birth: ______________________ EMAIL (print clearly) :______________________@______________ Place of Employment: _____________________

2) Parent/Guardian’s Name : ___________________________________________

Address ( IF DIFFERENT FROM STUDENT) ________________________________ Separate Mailing? Yes ❐ No ❐ Phone (call 2nd):__________________ circle: HOME CELL WORK | Phone (call 3rd):_________________ circle: HOME CELL WORK Speaks English? Yes _____ If No, Language _________________ Country of Birth: ______________________ EMAIL (print clearly) :______________________@______________ Place of Employment: _____________________

* If your child is to be transported by Milford Public Schools to and from a diﬀerent address - NOT home (example day care, babysi er, grandparent, etc.), this address must be within your child’s assigned school district .

MEMORIAL OR BROOKSIDE SCHOOL (K - 2 ONLY) IS DETERMINED BY YOUR HOME ADDRESS

Please indicate the address for transporta on (if diﬀerent from home), contact and phone number below. If this informa on should change, please no fy the school immediately.

* ADDRESS:__________________________________________________NAME:____________________________PHONE:_______________________

Please note: This accommoda on can ONLY be made at the beginning of the school year, before bus assignments have been ﬁnalized, and cannot be changed during the school year

Preparer and/or Interpreter Cer ﬁca on (check one):

❐ I did not need a preparer or interpreter OR ❐ A preparer or interpreter assisted me with the comple on of these forms. Name of Preparer or Interpreter: _____________________________________

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Student Registra on Requirements

HOME LANGUAGE SURVEY

State and Federal Laws require that all schools determine the language(s) spoken in each

student’s home in order to iden fy their speciﬁc language needs. This informa on is essen al

in order for schools to provide meaningful instruc on for all students . If a language other than

English is spoken in the home, the District is required to do further assessment of your child.

Please help us meet this important requirement by answering the following ques ons.

Thank you for your assistance.

Student Informa on

Student’s Name: _________________________________________________________________________________

Country of Birth: ______________ Date of Birth: _____/_____/20____ Gender: Male

❐

Female

❐

Non-binary

❐

School Informa on

(Not necessary for Kindergarten or Preschool enrollment)

Current Grade: ______ Date ﬁrst enrolled in ANY U.S. school ______/_____/20______

Previous School and Town ______________________________________________________________

Ques ons for Parents/Guardians

What is the primary language used in the home, regardless of the language spoken by the student?

Which language(s) are spoken with your child? (circle one)

1)________________ seldom / some mes/ o en / always By whom (circle): mother, father, grandparents, uncles, aunts, caregiver, other ________________

2)________________ seldom / some mes/ o en / always By whom (circle): mother, father, grandparents, uncles, aunts, caregivers, other _______________

What language did your child ﬁrst understand and speak?

Which language do you use most o en with your child?

Which language(s) does your child use? (circle one)

1)________________ seldom / some mes/ o en / always By whom (circle): mother, father, grandparents, uncles, aunts, caregiver, other ________________

2)________________ seldom / some mes/ o en / always By whom (circle): mother, father, grandparents, uncles, aunts, caregivers, other _______________

How many years has the student been in U.S. Schools?

Will you require wri en informa on from school

translated into your na ve language? Yes ❐ No ❐

Will you require an interpreter at Parent-Teacher mee ngs? Yes ❐ No ❐

X ____________________________________________

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Student Registra on Requirements

Race and Ethnicity Ques onnaire

Student's name: __________________________________________________________ Current Grade: ________

Student's Date of Birth: _______/______/20_______ Student's City /Town of Birth: _________________________ Month / Day / Year

Language Spoken at Home: _____________________________ Country of Origin: _________________________

Please answer BOTH ques ons 1 and 2.

1. Is this student Hispanic or La no? (choose only one)

❐

No , not Hispanic or La no

❐

Yes , Hispanic or La no (Spanish origin): A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin , regardless of race.

2. What is the student's race? (choose one or more)

❐

White/Caucasian (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

❐

Black or African American (A person having origins in any of the black racial groups of Africa.)

❐

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcon nent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

❐

Na ve American or Alaska Na ve (A person having origins in any of the original peoples of North and South American (including Central America), and who maintains tribal aﬃlia on or community a achment.)

❐

Na ve Hawaiian or Other Paciﬁc Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Paciﬁc Islands.)

Milford Public Schools

Residency Policy

Sec on I: To be read and signed by Parent/Guardian:

It is the policy of the Milford Public Schools that any student who does not live in Milford must a end school in the community where he/she lives. If the school administra on determines that you do not live in Milford, your child/ren will be withdrawn from this school district.

A Change of Address form must be completed and submi ed with a new Resident Card to the school oﬃce whenever there is a change of address . Transporta on will not be added or changed un l the Change of Address form and the new Resident Card have been received.

The Milford Public Schools reserves the right to have the resident informa on veriﬁed by the Assistant Superintendent at any me.

This residency policy does not apply to homeless students (see below).

X ____________________________________________ _______ /________/20______

Parent/Guardian signature Today's Date

Sec on II: Eligibility for McKinney-Vento Services:

Are you sharing the housing of other persons due to loss of housing, economic hardship or a similar reason? Yes ❐ No ❐

If yes:

Would you like someone to contact you with informa on about services to which you may be en tled? Yes ❐ No ❐

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Student Registra on Requirements

Student Educa onal History

Student's name: ___________________________________________________________________________

Current Assigned Grade: ________ Student's Date of Birth: __________/____/20_______

Date ﬁrst enrolled in ANY U.S. school _____________/____/20______

Grade School Year Student's age Name of School City, State, Country Private Public/ Language of Instruc on ESL ? IEP ? 504 ?

PK 20___-20___ English? Other?_________ K 20___-20___ English? Other?_________ 1 20___-20___ English? Other?_________ 2 20___-20___ English? Other?_________ 3 20___-20___ English? Other?_________ 4 20___-20___ English? Other?_________ 5 20___-20___ English? Other?_________ 6 20___-20___ English? Other?_________ 7 20___-20___ English? Other?_________ 8 20___-20___ English? Other?_________ 9 20___-20___ English? Other?_________ 10 20___-20___ English? Other?_________ 11 20___-20___ English? Other?_________ 12 20___-20___ English? Other?_________

Has this student ever been retained? No ❐ Yes ❐ If yes, grade _____________________ Has this student ever had interrup ons in their schooling? No ❐ Yes ❐ If yes, explain:

__________________________________________________________________________________________________ __________________________________________________________________________________________________ Has this student ever been suspended or expelled from school? No ❐ Yes ❐ If yes, explain:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

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Student Registra on Requirements

Nursing Department

School: _____________________________ Current Grade:_________ YOG: ___________

Student’s Name : ______________________________________________________ Date of Birth: ____ /____ /20____

Last Name First Name Middle Name Month / Day / Year

Student’s Home Address: _______________________________ Gender: Male

❐

Female

❐

Non-binary

❐

Home Phone Number: _________________________ Home Language: __________________________

Parent 1/Guardian’s Name : __________________________________________________________

Parent 1/Guardian’s Place of Employment: __________________________________ Work Number: _______________ Parent 1/Guardian’s Cell Phone Number: _________________________________ EMAIL:________________________

Parent 2/Guardian’s Name : ____________________________________________________________

Parent 2/Guardian’s Place of Employment: _________________________________ Work Number: ______________ Parent 2/Guardian’s Cell Phone Number: _________________________________ EMAIL:________________________

HEALTH ASSESSMENT:

Question Yes No If Yes, Specify:

1. Does your child have any medical problems? 2. Does your child have any chronic health problems?

3. Has your child ever had surgery?

4. Does your child have any allergies to food? 5. Does your child have any allergies to bees? 6. Does your child have any allergies to the environment? 7. Does your child have any allergies to medica on?

8. Does your child have an Epipen?

9. Does your child take any medica on on a regular basis? 10. Does your child have any vision and/or hearing

problems?

11. Has your child ever been evaluated by a specialist? Comments:

X ____________________________________________ _______ /________/20______

_______________________________________________________ School Nurse Signature

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Student Registra on Requirements

Medical Informa on Release

Mailing Address:

Lee Waingor n, MSN, RN

Phone:

Director of Nursing

508-478-1135 x 1167

Milford Public Schools

FAX:

31 West Fountain Street

508-473-4195

Milford, MA 01757

Student's Physician:

___________________________________

Phone:

___________________________________

FAX:

___________________________________

Student's Name: ________________________________

Date of Birth: ____/_/20___

While my child is enrolled in Milford Public Schools, I authorize the exchange of per nent

medical informa on between my child's doctor's oﬃce and their school nurse.

X ____________________________________________ _______ /________/20_____

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Student Registra on Requirements

PEDIATRIC TB RISK ASSESSMENT FORM

(To be completed by medical provider)

The purpose of t h e TB Risk Assessment Form is to identify children who may be at increased risk for tuberculosis (TB) and may require evaluation and testing. A child with any risk factor described below is a candidate for TB

testing, unless there is written documentation of a previous positive TB test (tuberculin skin test [TST] or interferon gamma release assay [IGRA]).

Child’s Name: ___________________________________ DOB: _______________ Date:________________

TB Risk Assessment Yes No

Was the child born in Africa, Asia and Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, the Caribbean or the Middle East?

If yes, in what country was the child born? ________________________________________

☐ ☐

Has the child lived or traveled in Africa, Asia and Pacific Islands (except Japan),

Central America, South America, Mexico, Eastern Europe, the Caribbean or the Middle East for more than one month?

☐ ☐

In the last 2 years, has the child lived with or spent time with someone who has been sick

with TB? ☐ ☐

Have any members of the child’s household come to the United States from another

country? ☐ ☐

Does the child have any history of immunosuppressive disease or take medications that

might cause immunosuppression? ☐ ☐

Test for TB

Report TB

Resources

Brochure “What Parents Need to Know About Tuberculosis (TB) Infection in Children”, New Jersey Medical School Global Tuberculosis Institute http://globaltb.njms.rutgers.edu/downloads/products/tbpedsbrochure.pdf

Screening Infants and Children for Tuberculosis in Massachusetts, MDPH 2014

http://www.mass.gov/eohhs/docs/dph/cdc/tb/recommendations-screening-children-tb.pdf

CDC recommendations on TB evaluation, testing and treatment in children

http://www.cdc.gov/tb/topic/populations/TBinChildren/default.htm

CDC Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children. MMWR September 2009 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5811a1.htm

MDPH supported TB clinics http://www.mass.gov/eohhs/gov/departments/dph/programs/id/tb/public-health-cdc-tb-clinics.html

Medical Provider Signature:___________________________________________ Date:___________________ Massachusetts Department of Public Health | Bureau of Infectious Disease

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Student Registra on Requirements

Student Resident Card

Milford Town Hall

52 Main St., Milford, MA 01757

phone: (508)634-2307 (Town Clerk),

fax: (508)634-2324 (all depart.)

Hours: Monday - Friday, 8:30 am - 4:30 pm

www.milford.ma.us

OBTAINING A RESIDENT CARD

A resident card is required for all new students.

You must go to the Town Clerk’s oﬃce at the Town Hall to obtain a resident card.

There is no fee for the Resident Card for school enrollment.

- - - *A homeowner must bring to Town Hall:

1. Purchase & Sales Agreement OR a copy of their Field Card from the Assessor’s Oﬃce, 2. the AFFIDAVIT OF RESIDENCY form (included in this enrollment packet), and

3. a photo ID

- - - *A renter must bring to Town Hall:

1. EITHER a copy of the LEASE ( only if lease lists names of all adults and children - If not, you are required to obtain a notarized le er (see below)).

OR a notarized le er from landlord/rental agent sta ng: - the address,

- names and dates of birth of all adults and children living in the home, - the landlord’s contact phone number and address

2. the AFFIDAVIT OF RESIDENCY form (included in this enrollment packet) signed by the landlord/rental agent (demonstra ng Housing Bylaw compliance) ; and

3. a photo ID

ALL OWNERS OF RENTAL PROPERTIES IN THE TOWN OF MILFORD MUST BE IN COMPLIANCE WITH THE TOWN OF MILFORD’S MAXIMUM OCCUPANCY BY-LAW. IF YOU ARE NOT IN COMPLIANCE, A RESIDENCY CARD WILL

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Student Registra on Requirements

AFFIDAVIT OF RESIDENCY

Proof of Residency

Board of Registrars/Town Clerk Town Hall, 52 Main Street, Room 12

Milford, MA 01757

Date: ____________________

Please change my address from ____________________________________________________________________ (old address)

to ___________________________________________________________________________________________ (new address in Milford- street and/or apt. #)

Mailing address if different:_______________________________________________________________________

*Please be advised that the Town of Milford has an Occupancy By-Law* (on reverse) Please Print :

Name Date of Birth Sex (circle) Phone#

1. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 2. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 3. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 4. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 5. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 6. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 7. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 8. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 9. ___________________________ ____/____ /_______ M - F ( ) ____ - _______ 10. __________________________ ____/____ /_______ M - F ( ) ____ - _______ Signed: ______________________________________________ (**By Homeowner or Landlord/Rental Agent)

**This form MUST accompany a lease or a notarized letter from the landlord listing all residents living at the above address, if you rent or a field card if you own the home**

HOMEOWNER IS REQUIRED TO PRESENT A PHOTO ID WHEN

SUBMITTING THIS FORM TO TOWN CLERK

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Student Registra on Requirements

OBTAINING A RESIDENT CARD

1-

If you rent:

please provide us with either: 1.) A notarized letter from the landlord that states the address, the names and dates of birth of all adults & children living at the property; letter must also include Landlord’s contact phone number and address OR 2.) A copy of the lease that lists all of the adults & children living at the property. (*be advised the Town of Milford has a Maximum Occupancy Bylaw). ALL OWNERS OF RENTAL PROPERTIES IN THE TOWN OF MILFORD MUST BE IN COMPLIANCE WITH THE TOWN OF MILFORD’S MAXIMUM OCCUPANCY BY-LAW. IF YOU ARE NOT IN COMPLIANCE, A RESIDENCY CARD WILL NOT BE ISSUED. BOARD OF HEALTH WILL CERTIFY COMPLIANCE.

2-

If you own the home :

please provide us with either 1.) A “field card” from the Assessor’s Office that lists the owners of the home OR 2.) a copy of your purchase and sales agreement (*be advised the Town of Milford has an Occupancy Bylaw)

3- There is no fee for the resident card ( for school purposes only ).

4- There is a $10.00 fee for a birth certificate (if needed). We DO NOT accept personal checks. Debit or credit cards; with a fee; are accepted in the office or online only. Cash or a money orders made out to the Town of Milford are accepted. 5- We DO NOT accept personal checks. Debit or credit cards; with a fee; are accepted in the office or online only. Cash or money orders made payable to the Town of Milford are accepted.

6- We will give you a form to list all residents in the household, and their dates of birth-we input this list into the computer and process the resident card when proper evidence is given (*you are required to notify this office and the school of any address changes). This process would apply every time you move within Milford.

7- Please provide photo identification with this form.

Any other questions, you can call the office at (508) 634-2307.

Town of Milford Occupancy By-Law (Article 37) *sections that apply to this form* SECTION 1. Definitions.

As used in this Article, the following terms shall have meanings indicated:

PERSON- The owner of any building and the owner's agent and employees and includes an individual, partnership, corporation, trust or association.

TENANT – Tenants, lessee, holder of a lease and any licensee or invitee of such tenant, and includes an individual, partnership, corporation, trust or association.

SECTION 2 . Certificate of Registration Required; Posting.

No person shall rent or lease, offer to rent or lease, or make or have available for rent or lease any building or any portion of a building to be used for human habitation without first registering with the Board of Health, which shall determine the number of persons such building or portion of a building may lawfully accommodate under the provisions of the Massachusetts State Sanitary Code and applicable Board of Health Regulations, and without first also conspicuously posting within such building or portion of a building a Certificate of Registration provided by the Board of Health specifying the number of persons such building or portion of a building may lawfully accommodate. This provision shall not apply to units or portions of buildings which are occupied by the record owner. SECTION 3. Number of Persons Restricted.

No tenant shall lease, rent, or occupy any building or any portion of a building subject to the provisions of this chapter if, at the time of such lease, rental or occupancy, the number of persons occupying such building or portion of a building exceeds the number of persons authorized to occupy such building or portion of a building by a certificate of registration, if issued and posted, the number of persons that may be lawfully accommodated as determined by the Board of Health under the Massachusetts State Sanitary Code SECTION 6. Penalty.

Any person or tenant violating any provision of this chapter shall be punished by a fine of not more than three hundred dollars ($300.00). Each day's violation constitutes a separate offense.

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Student Registra on Requirements

Release of SCHOOL Records

School Name (transferring from): __________________________________________________ Address: ___________________________________________________ City, State: _________________________________________________ Phone: ____________________________________________________ FAX: ______________________________________________________

Name _______________________________________________, Date of Birth ____/____/20______,

(Student Name) month / day / year

has recently enrolled in the Milford Public School system.

Please forward the following records to the address checked below: x Transfer Card

x Transcript x Report Cards x A endance History x Discipline History

x Tes ng (MCAS, ACCESS for ELLs, WIDA Screener/MODEL, ETC.) x Special Educa on, 504, etc (if applicable)

x Other (_______________________________________)

X ____________________________________________ _______ /________/20_____

The Family Resource Center 31 West Fountain St. Milford, MA 01757

ph: 508-478-1135 x4603 fax:508-473-1601 ATTN: FRC Manager

Shining Star Early Childhood Center 31 West Fountain St. Milford, MA 01757

ph:508-478-1135 x0608 fax:508-473-1601 ATTN: School Secretary

Memorial Elementary School 12 Walnut St. Milford, MA 01757

ph:508-478-1689 fax:508-634-1486 ATTN: School Secretary

Brookside Elementary School 110 Congress St. Milford, MA 01757 ph:508-478-1177 x4620 fax:508-634-2375 ATTN: School Secretary

Woodland Elementary School 10 North Vine St. Milford, MA 01757 ph:508-478-1186 x0 fax:508-478-1695 ATTN: School Secretary

Stacy Middle School Guidance Oﬃce 66 School St. Milford, MA 01757

ph:508-478-1167 x507 fax:508-634-2370 ATTN: Guidance Secretary

Milford High School Guidance Oﬃce 31 West Fountain St. Milford, MA 01757

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Student Registra on Requirements

SCHOOL NURSE - Release of School HEALTH Records

School Name (transferring from): ___________________________________________________ Address: ____________________________________________________ City, State: __________________________________________________ Phone: _____________________________________________________ FAX: _______________________________________________________

Name _______________________________________________, Date of Birth ____/____/20______,

(Student Name) month / day / year

has recently enrolled in the Milford Public School system.

Please forward the following records to the address checked below: x Health Record

x MOST Current Physical Exam from MD oﬃce/clinic x List of all immuniza ons

x Care Plan (if applicable)

x Other (_______________________________________)

X ____________________________________________ _______ /________/20_____

The Family Resource Center 31 West Fountain St. Milford, MA 01757

ph: 508-478-1135 x1167 fax:508-473-4195 ATTN:Lee Waingor n, MSN, RN

Shining Star Early Childhood Center 31 West Fountain St. Milford, MA 01757 ph: 508-478-1135 x1167 fax:508-473-4195 ATTN: School Nurse

Memorial Elementary School 12 Walnut St. Milford, MA 01757 ph: 508-478-1194 fax:508-473-4212 ATTN: School Nurse

Brookside Elementary School 110 Congress St. Milford, MA 01757 ph: 508-478-1168 fax: 508-473-4277 ATTN: School Nurse

Woodland Elementary School 10 North Vine St. Milford, MA 01757 ph: 508-478-1186 x3061 fax:508-473-4280 ATTN: School Nurse

Stacy Middle School Health Oﬃce 66 School St. Milford, MA 01757 ph:508-478-1494 fax:508-473-4552 ATTN: School Nurse