Deerstream

Student's Name	Anne Rebecca Hummel
Date Of Birth	08/08/2014
T shirt size	Child L
PARENT INFORMATION
Parent 1	Abigail Hummel
Cell Phone	(515) 509-3857
Home/Work Phone	(515) 509-3857
Parent 2	Aaron Hummel
Cell Phone	(314) 267-4050
Emergency Contact 1	Elizabeth Abbason
Relationship	Friend
Phone Number	(631) 921-9081
Emergency Contact 2	Cathy Durham
Relationship	Friend
Phone Number	(919) 641-0116
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Sean Harper
Physician's Phone Number	919-823-6491
Preferred Medical Facility	Duke (any is fine)
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	Aaron Hummel
Employer	Pairwise
Insurance Company	BlueCross BlueShield
Policy Number	RGF103716298
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	Abigail Hummel
Signature