| Student's Name | Jonathan Peter Campbell |
|---|---|
| Date Of Birth | 03/29/2016 |
| T shirt size | Child S |
| PARENT INFORMATION | |
| Parent 1 | Timothy Campbell |
| Cell Phone | (937) 681-1664 |
| Home/Work Phone | (937) 681-1664 |
| Parent 2 | Amber Campbell |
| Cell Phone | (937) 681-1565 |
| Home/Work Phone | (937) 681-1565 |
| Emergency Contact 1 | Becky Morlan |
| Relationship | Grandma |
| Phone Number | (330) 354-8210 |
| Emergency Contact 2 | Barbara 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 | 9197329311 |
| 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 |
| What other information will help us to provide a safe and accessible environment for your child? | None |
| Insurance | |
| Name of Policy Holder | Jonathan Campbell |
| Employer | N/A |
| Insurance Company | NC Medicaid |
| Policy Number | 954391774o (not a typo, O not zero) |
| 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 |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
