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Student's NameAugust Lilly
Date Of Birth10/14/2016
T shirt sizeChild S
PARENT INFORMATION
Parent 1Amy Lilly
Cell Phone(919) 308-4589
Home/Work Phone(919) 308-4589
Parent 2Amy Lilly
Cell Phone(804) 301-5656
Emergency Contact 1Amy Lilly
RelationshipMother
Phone Number(919) 308-4589
Emergency Contact 2Peggy Waters
RelationshipGrandmother
Phone Number(919) 308-3677
ALLERGY INFORMATION
Does this child have any known allergies?Yes
If yes, please name the allergy/allergies.
  • Oral Contact allergy to pineapple, peaches, kiwi
Please describe the situation and severity of the allergy. For instance, some children are allergic to egg but can eat eggs in baked goods, while others have a sensitivity to the presence of the allergen in the environment.

Not severe. If eaten, they will causes sores on his tongue called atopic stomatitis.

Please describe the warning signs or symptoms of an allergic reaction.

He will say his tongue is tingling, stinging, burning.

In case of allergic reaction, please describe exactly what steps we should take.

The only way to correct it is for him to eat a tums (calcium carbonate tab) or drink milk/water to try to rinse the fruit acids from his mouth.

Does this child carry Benadryl or an epipen?no
OTHER MEDICAL INFORMATION
Physician's NameDr. Katherine Delgado
Physician's Phone Number(919) 967-0771
Preferred Medical FacilityChapel Hill Children’s Clinic
Current Medications and Dosages

Fluoxetine 5mg
Olanzapine 5 mg

Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.

Avoidant Restrictive Food Intake Disorder (ARFID) - an anxiety/fear based eating disorder. He is medicated and followed by Dukes psychiatry and feeding ARFID team. No limitations in his activity and no need for any intervention from school.

Will your child need the learning environment or assignments adapted in any way?No
Insurance
Name of Policy HolderAlexander Lilly
EmployerPulte Home Corporation
Insurance CompanyUnited Healthcare
Policy Number985460599
SIGNATUREI, 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.
NameAmy Lilly
Signature