Deerstream

Student's Name	Evelyn Violet Day
Date Of Birth	11/01/2014
T shirt size	Child S
PARENT INFORMATION
Parent 1	Lindsay Day
Cell Phone	(561) 843-1917
Home/Work Phone	(561) 843-1917
Parent 2	Phillip Day
Cell Phone	(415) 259-8101
Emergency Contact 1	Colleen Blanding
Relationship	grandmother
Phone Number	(561) 843-1964
Emergency Contact 2	Rebekah Davis
Relationship	friend
Phone Number	(909) 758-3518
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Laura Bowen
Physician's Phone Number	919-732-9311
Preferred Medical Facility	UNC or Duke
Current Medications and Dosages	N/A
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Lindsay Day
Employer	Kenvue
Insurance Company	Aetna
Policy Number	W2797 98821 02
SIGNATURE	I, as parent or legal guardian, do hereby grant Deerstream faculty and trustees present the right to authorize emergency medical treatment for my child, named above, in the event that my designated representatie or I cannot be reached. I agree to hold harmless Deerstream and its agents from liability arising out of accident situations. The North Carolina Good Samaritan Law will apply.
Name	Lindsay Day
Signature