Deerstream

Student's Name	Isabel Lois Johnsen
Date Of Birth	07/02/2012
T shirt size	Child XL
PARENT INFORMATION
Parent 1	Anna Johnsen
Cell Phone	(919) 454-6966
Home/Work Phone	(919) 321-8643
Parent 2	Ben Johnsen
Cell Phone	(919) 434-4142
Emergency Contact 1	sandra kiser
Relationship	grandmother
Phone Number	(828) 461-8507
Emergency Contact 2	olivia cil
Relationship	aunt
Phone Number	(704) 530-1934
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	chapel hill peds
Physician's Phone Number	919-942-4173
Current Medications and Dosages	na
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Ben Johnsen
Employer	nvidia
Insurance Company	cigna
Policy Number	81813740004
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	Anna Johnsen
Signature