Deerstream

Student's Name	Piper Ellen Pettigrew
Date Of Birth	03/05/2015
T shirt size	Child M
PARENT INFORMATION
Parent 1	Kelly Pettigrew
Cell Phone	(919) 265-4402
Home/Work Phone	(919) 265-4402
Parent 2	Malcolm Pettigrew
Cell Phone	(919) 265-4688
Emergency Contact 1	Kristen Thompson
Relationship	friend
Phone Number	(919) 922-4301
Emergency Contact 2	Scott Thompson
Relationship	friend
Phone Number	(919) 920-6226
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Dana Nuetze
Physician's Phone Number	(984) 974-0210
Preferred Medical Facility	UNC
Current Medications and Dosages	NA
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Malcolm Pettigrew
Employer	Hillsborough Community Church
Insurance Company	BCBS NC
Policy Number	YPS103265159
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	Kelly Pettigrew
Signature