Deerstream

Student's Name	Maximilian James Posey
Date Of Birth	10/23/2015
T shirt size	Child M
PARENT INFORMATION
Parent 1	Jennifer Posey
Cell Phone	(919) 357-4505
Home/Work Phone	(919) 357-4505
Parent 2	Hollis “Jay” Posey
Cell Phone	(919) 357-4504
Emergency Contact 1	Cindy Bagwell
Relationship	Grandmother
Phone Number	(570) 204-8235
Emergency Contact 2	Betty Garcia
Relationship	Friend
Phone Number	(919) 219-7049
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Esther Jeong/Duke Children’s
Physician's Phone Number	919-620-5333
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	Hollis Posey
Employer	Victura/Highwire Games
Insurance Company	Regence BlueShield/BCBC OOS
Policy Number	ZLF220073636
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	Jennifer Posey
Signature