Deerstream

Student's Name	August Jasper Grant
Date Of Birth	06/17/2017
T shirt size	Child S
PARENT INFORMATION
Parent 1	Chelsea Grant
Cell Phone	(562) 755-1597
Home/Work Phone	(562) 755-1597
Parent 2	Geoff Grant
Cell Phone	(626) 261-3588
Emergency Contact 1	Chelsea Grant
Relationship	Mother
Phone Number	(562) 755-1597
Emergency Contact 2	Geoff Grant
Relationship	Father
Phone Number	(626) 261-3588
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Andrews
Physician's Phone Number	919-933-8381
Preferred Medical Facility	UNC
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	Geoffrey Grant
Employer	Chapel Hill Bible Church
Insurance Company	Blue Cross Blue Shield
Policy Number	YPS103265163
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	Chelsea Grant
Signature