| Student's Name | Irelyn Mae Engelbrecht |
|---|---|
| Date Of Birth | 01/06/2013 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Matt Stoudt |
| Cell Phone | (215) 275-0053 |
| Home/Work Phone | (215) 275-0053 |
| Parent 2 | Morgan Stoudt |
| Cell Phone | (919) 225-5186 |
| Home/Work Phone | (919) 225-5186 |
| Emergency Contact 1 | Mary Roberson |
| Relationship | Grandmother |
| Phone Number | (252) 241-8225 |
| Emergency Contact 2 | Jessica Claire Jones |
| Relationship | Family Friend |
| Phone Number | (919) 619-2486 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | May Slowick |
| Physician's Phone Number | 919.620.5333 |
| Current Medications and Dosages | methylphenidate 10mg daily |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Irelyn is diagnosed with inattentive ADHD and dyslexia. |
| 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? | Irelyn is sweet and eager to learn. She struggles with reading, as a result of a combination of ADHD and Dyslexia. She is bridging the reading gap, thanks to great coaching with another Deerstream mom, Kelly Rocke. She also may share, at her discretion, that her biological father passed away in 2017 after a long battle with cancer. Our family is obviously reshaped now, with a new dad and a new baby brother in the picture. We recognize it as the grace of the Lord that carries us through, and Irelyn seems to be doing well. However, we felt like a heads up to your teaching staff and administration would be good. |
| Insurance | |
| Name of Policy Holder | Irelyn Engelbrecht |
| Employer | N/A |
| Insurance Company | HealthyBlue |
| Policy Number | 0000 |
| 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 | Matt Stoudt |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
