| Student's Name | Virginia Bell Thielman |
|---|---|
| Date Of Birth | 06/10/2017 |
| T shirt size | Child XS |
| PARENT INFORMATION | |
| Parent 1 | Erin Thielman |
| Cell Phone | (984) 234-8945 |
| Home/Work Phone | (984) 234-8945 |
| Parent 2 | Jacob Thielman |
| Cell Phone | (984) 234-8944 |
| Home/Work Phone | (984) 234-8944 |
| Emergency Contact 1 | Karen Somerville |
| Relationship | grandmother |
| Phone Number | (517) 610-2882 |
| Emergency Contact 2 | Elizabeth Thielman |
| Relationship | aunt |
| Phone Number | (703) 343-0567 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Yun Boylston |
| Physician's Phone Number | 919-563-0202 |
| Preferred Medical Facility | UNC Children's Hospital |
| Current Medications and Dosages | n/a--(5 mL Claritin in spring and fall for seasonal allergies) |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | n/a |
| 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? | Virginia loves people and loves Deerstream! |
| Insurance | |
| Name of Policy Holder | Virginia Thielman |
| Employer | n/a |
| Insurance Company | WellCare of North Carolina |
| Policy Number | 31804293 |
| 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 | Erin Thielman |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
