Deerstream

Student's Name	Luke Nevin Benoit
Date Of Birth	10/17/2008
T shirt size	Adult Unisex XL
PARENT INFORMATION
Parent 1	Jennifer Benoit
Cell Phone	(919) 349-3836
Home/Work Phone	(919) 381-5176
Parent 2	Timothy Benoit
Cell Phone	(919) 638-6386
Home/Work Phone	(919) 381-5176
Emergency Contact 1	Stephanie Corbett
Relationship	Family Friend
Phone Number	(919) 358-2021
Emergency Contact 2	Erin Ting
Relationship	Family Friend
Phone Number	(984) 222-5631
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Ann Rand
Physician's Phone Number	919-477-2202
Preferred Medical Facility	Regional Pediatrics or closest
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	Timothy Benoit
Employer	Harris Teeter
Insurance Company	CIGNA
Policy Number	u53816186 03
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	Jennifer Benoit
Signature