Deerstream

Student's Name	Elyza Grace Muleta
Date Of Birth	06/12/2014
T shirt size	Child L
PARENT INFORMATION
Parent 1	Mitchow Muleta
Cell Phone	(919) 491-0510
Home/Work Phone	(919) 491-0510
Parent 2	Mark Muleta
Cell Phone	(919) 308-1321
Emergency Contact 1	Mitchow Muleta
Relationship	Mother
Phone Number	(919) 491-0510
Emergency Contact 2	Mark Muleta
Relationship	Father
Phone Number	(919) 308-1321
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Esther Jeong
Physician's Phone Number	(919) 620-5333
Preferred Medical Facility	Duke
Current Medications and Dosages	None
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	None
Will your child need the learning environment or assignments adapted in any way?	No
What other information will help us to provide a safe and accessible environment for your child?	None
Insurance
Name of Policy Holder	Mark Muleta
Employer	Veterans Hospital Durham
Insurance Company	BCBS Federal
Policy Number	R59050561
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	Mitchow Muleta
Signature