Deerstream

Student's Name	Teddy Blasingame
Date Of Birth	04/29/2019
T shirt size	Child XS
PARENT INFORMATION
Parent 1	Becky Blasingame
Cell Phone	(406) 253-3452
Home/Work Phone	(406) 253-3452
Parent 2	James Blasingame
Cell Phone	(919) 358-2314
Emergency Contact 1	Jeannine OBrian
Relationship	Friend
Phone Number	(716) 465-1684
Emergency Contact 2	Erin Bluschke
Relationship	Friend
Phone Number	(919) 930-4602
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Scot Woodrum
Physician's Phone Number	919-492-4173
Preferred Medical Facility	UNC Children’s
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	James Blasingame
Employer	CData
Insurance Company	Cigna
Policy Number	105395661
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	Rebecca Blasingame
Signature