Deerstream

Student's Name	Henry G L Milsom
Date Of Birth	03/05/2011
T shirt size	Adult Unisex S
PARENT INFORMATION
Parent 1	Melissa Milsom
Cell Phone	(443) 838-8079
Home/Work Phone	(443) 838-8079
Parent 2	Greg Milsom
Cell Phone	(410) 404-4798
Emergency Contact 1	Deb Milsom
Relationship	Grandmother
Phone Number	(919) 951-7651
Emergency Contact 2	Gary Milsom
Relationship	Grandfather
Phone Number	(301) 472-0931
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Priyanka Rao
Physician's Phone Number	9842154550
Preferred Medical Facility	UNC
Current Medications and Dosages	Focalin 10mg 2x AM
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Melissa Milsom
Employer	Epsilon
Insurance Company	BCBS
Policy Number	PGI825410081
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	Melissa Milsom
Signature