| Student's Name | Tierney Loretta Schmidt |
|---|---|
| Date Of Birth | 12/31/2007 |
| T shirt size | Women's Cut M |
| PARENT INFORMATION | |
| Parent 1 | Anna Schmidt |
| Cell Phone | (919) 619-5394 |
| Home/Work Phone | (919) 619-5394 |
| Parent 2 | Trevor Schmidt |
| Cell Phone | (919) 619-5393 |
| Home/Work Phone | (919) 619-5393 |
| Emergency Contact 1 | Stacy Green |
| Relationship | Friend |
| Phone Number | (919) 900-0956 |
| Emergency Contact 2 | Jennifer Norris |
| Relationship | Friend |
| Phone Number | (919) 358-6577 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | Yes |
| If yes, please name the allergy/allergies. |
|
| 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. | The allergy is serious only if she directly consumes the nuts. Items processed in a factory with treenuts are okay. |
| Please describe the warning signs or symptoms of an allergic reaction. | She immediately feels her tongue and lips start to swell. |
| In case of allergic reaction, please describe exactly what steps we should take. | Benadryl should be administered immediately, followed by an EpiPen if symptoms worsen. |
| Does this child carry Benadryl or an epipen? | yes |
| What is it and where will it be located? (In the lunchbox, in the front pocket of the bookbag, etc.). What is the dosage and indication for the medicine? Can your child self-administer or will he need help? (In general, we don't allow teachers to administer medications except in emergency situations.) | In her bag. She can self administer. |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Kirsche |
| Physician's Phone Number | 919-806-3335 |
| Preferred Medical Facility | UNC |
| 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 | Trevor Schmidt |
| Employer | Hutchinson |
| Insurance Company | Arena |
| Policy Number | W222867722 |
| 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 | Anna Schmidt |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
