Deerstream

Student's Name	Sara Violet Stults
Date Of Birth	03/01/2011
T shirt size	Women's Cut S
PARENT INFORMATION
Parent 1	Kristin Stults
Cell Phone	(984) 234-9084
Home/Work Phone	(919) 382-8270
Parent 2	Ryan Stults
Cell Phone	(919) 452-9349
Home/Work Phone	(919) 382-8270
Emergency Contact 1	Alexa Gerend
Relationship	Friend
Phone Number	(919) 452-6883
Emergency Contact 2	Sarah Coonley
Relationship	Friend
Phone Number	(919) 308-1865
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Sara Page
Physician's Phone Number	9196205333
Preferred Medical Facility	Duke Regional
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
Insurance
Name of Policy Holder	Ryan Stults
Employer	Duke University
Insurance Company	Aetna
Policy Number	W2315 70471
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	Kristin Stults
Signature