Deerstream

Student's Name	Samuel Mateo Fengler-Rodriguez
Date Of Birth	12/08/2007
T shirt size	Adult Unisex M
PARENT INFORMATION
Parent 1	irene rodriguez
Cell Phone	(919) 972-1483
Home/Work Phone	(919) 972-1483
Parent 2	sebastian fengler
Cell Phone	(919) 897-3111
Home/Work Phone	(919) 448-6269
Emergency Contact 1	Jaime Rodriguez
Relationship	paternal grandfather
Phone Number	(919) 972-1632
Emergency Contact 2	Anikke Conway
Relationship	family friend and neighbor
Phone Number	(919) 224-9956
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	dr. Harper
Physician's Phone Number	9199670771
Preferred Medical Facility	the closest (unc or duke)
Current Medications and Dosages	n/a
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	sebastian fengler
Employer	Indulor america lp
Insurance Company	bcbs
Policy Number	YPS101257647
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	IRENE RODRIGUEZ
Signature