Deerstream

Student's Name	Annabelle Jane Wright
Date Of Birth	07/09/2010
T shirt size	Women's Cut M
PARENT INFORMATION
Parent 1	Julie Wright
Cell Phone	(858) 204-2388
Home/Work Phone	(858) 204-2388
Parent 2	Michael Wright
Cell Phone	(919) 308-2672
Home/Work Phone	(919) 308-2672
Emergency Contact 1	Paula Wright
Relationship	Grandmother
Phone Number	(302) 542-2852
Emergency Contact 2	Kelly Rocke
Relationship	Friend
Phone Number	(919) 808-6425
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Kathleen T. Murphy & Lisa Ferrari
Physician's Phone Number	(919) 220-4000
Preferred Medical Facility	Duke
Current Medications and Dosages	Methylphenidate ER 27MG, Methylphenidate 10MG
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	ADHD moderate, combination
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Michael Wright
Employer	Duke Law School
Insurance Company	Aetna/Duke Basic
Policy Number	W2317 39105
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	Julie Wright
Signature