Deerstream

Student's Name	Estela Ines Tarajano
Date Of Birth	10/07/2017
T shirt size	Child S
PARENT INFORMATION
Parent 1	Meredith Tarajano
Cell Phone	(225) 975-9056
Home/Work Phone	(225) 975-9056
Parent 2	Alberto Tarajano
Cell Phone	(225) 806-2983
Emergency Contact 1	Alberto Tarajano
Relationship	Father
Phone Number	(225) 806-2983
Emergency Contact 2	Meredith Tarajano
Relationship	Mother
Phone Number	(225) 975-9056
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Chapel hill pediatrics
Physician's Phone Number	919-942-4173
Preferred Medical Facility	Duke
Current Medications and Dosages	Aspirin (until November) Inhaler
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	Asthma Atrial septal defect closure 5/23- no physical limitations
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Alberto Tarajano
Employer	Pala
Insurance Company	UMR
Policy Number	29874822
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	Meredith Tarajano
Signature