Deerstream

Student's Name	Matthew Isaac Campbell
Date Of Birth	11/15/2010
T shirt size	Adult Unisex M
PARENT INFORMATION
Parent 1	Amber Campbell
Cell Phone	(937) 681-1565
Home/Work Phone	(937) 681-1565
Parent 2	Timothy Campbell
Cell Phone	(937) 681-1664
Home/Work Phone	(937) 681-1664
Emergency Contact 1	Becky Morlan
Relationship	Grandma
Phone Number	(330) 354-8210
Emergency Contact 2	Barb Campbell
Relationship	Grandma
Phone Number	(937) 620-6322
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Patrick Mullen
Physician's Phone Number	919-732-9311
Preferred Medical Facility	UNC Hospital
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 Campbell
Employer	Chapel Hill Carrboro City Schools
Insurance Company	Blue Cross Blue Shield
Policy Number	YPY104341409
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	Timothy Campbell
Signature