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.

Student Contact Verification Form
Student No.1
Student No. 2
Student No. 3
Student No. 4
Home address:
Mailing address:
Home telephone number:
Father's name:
Father's Address (if different):
Father's home number (if different):
Father's cell phone number:
Father's work Number:
Father's Email Address:
Mother's name:
Mother's address (if different):
Mother's home number (if different):
Mother's cell phone:
Mother's work number:
Mother's email address:
Telephone numbers for attendance calls (JSHS Only):
Emergency contact #1:
Emergency contact home telephone number:
Emergency contact cell phone number:
Emergency contact work telephone number:
Relationship to student:
Any additional information that you feel the school district should be made aware of: (If related to medical condition, you must contact the health office - please do not enter medical information on this form) Thank You.
Enter the number below to submit your information.


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