Deerstream

Student's Name	Samuel Luke Gardner
Date Of Birth	11/29/2007
T shirt size	Adult Unisex M
PARENT INFORMATION
Parent 1	Jeffrey Gardner
Cell Phone	(919) 619-3876
Home/Work Phone	(336) 212-0669
Parent 2	Martha Gardner
Cell Phone	(984) 244-3022
Home/Work Phone	(919) 563-3195
Emergency Contact 1	Lydia White
Relationship	Family friend
Phone Number	(919) 563-6065
Emergency Contact 2	Sarah Thrasher
Relationship	Family friend
Phone Number	(919) 627-1491
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Danté Lewis
Physician's Phone Number	919.563.0202
Preferred Medical Facility	UNC Children’s Hospital
Current Medications and Dosages	None
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	Autism
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Jeffrey Gardner
Employer	LabCorp
Insurance Company	Cigna
Policy Number	U56972646 05
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	Martha Gardner
Signature