Deerstream

Student's Name	Stuart Lemuel Honeycutt
Date Of Birth	04/27/2015
T shirt size	Child S
PARENT INFORMATION
Parent 1	Catherine Honeycutt
Cell Phone	(919) 358-7330
Home/Work Phone	(919) 358-7330
Parent 2	Miles Honeycutt
Cell Phone	(919) 619-3413
Emergency Contact 1	Martha Jennison
Relationship	grandmother
Phone Number	(919) 824-1073
Emergency Contact 2	Lauren Connolly
Relationship	neighbor
Phone Number	(215) 850-5672
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Doug Clark
Physician's Phone Number	9193671258
Preferred Medical Facility	Duke
Current Medications and Dosages	none
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Catherine Honeycutt
Employer	Self employed
Insurance Company	MEdishare Health Cost Sharing
Policy Number	03950H40474
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	Catherine Honeycutt
Signature