Deerstream

Student's Name	James Loren Rose
Date Of Birth	09/14/2011
T shirt size	Child L
PARENT INFORMATION
Parent 1	Clare Rose
Cell Phone	(609) 577-9614
Home/Work Phone	(609) 577-9614
Parent 2	John Rose
Cell Phone	(515) 230-5583
Home/Work Phone	(515) 230-5583
Emergency Contact 1	Katherine Rohrer
Relationship	Grandmother
Phone Number	(609) 468-5259
Emergency Contact 2	John Sully
Relationship	Grandfather
Phone Number	(609) 651-0889
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Elliott Sally
Physician's Phone Number	919-657-9770
Preferred Medical Facility	Duke University Hospital
Current Medications and Dosages	N/a
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	N/a
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	John Rose
Employer	Duke University
Insurance Company	Aetna
Policy Number	W237459835
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	Julian Rose
Signature