| Student's Name | Annabelle Paloma Edwards |
|---|---|
| Date Of Birth | 04/17/2007 |
| T shirt size | Women's Cut XL |
| PARENT INFORMATION | |
| Parent 1 | Lauralea Edwards |
| Cell Phone | (425) 238-6373 |
| Home/Work Phone | (919) 493-7897 |
| Parent 2 | Stephen Edwards |
| Cell Phone | (425) 238-4219 |
| Home/Work Phone | (425) 238-4219 |
| Emergency Contact 1 | Lauralea Edwards |
| Relationship | Mother |
| Phone Number | (425) 238-6373 |
| Emergency Contact 2 | Eliana Edwards |
| Relationship | Sister |
| Phone Number | (919) 704-0929 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Susan Kirsch |
| Physician's Phone Number | 919-806-3335 |
| Preferred Medical Facility | UNC |
| Current Medications and Dosages | Adderall XR 30mg |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Diagnosed with multiple learning differences related to working memory, executive function, processing speed, etc. and also muscle tone problems which affect balance and fine motor skills; however, these have not significantly affected her ability to perform well at Deerstream in years past. She also was diagnosed with abnormal uterine bleeding, but this is currently being treated with transdermal hormone patches. |
| Will your child need the learning environment or assignments adapted in any way? | Yes |
| If so, please describe. | Not necessarily, but please see above. Writing by hand and activities involving fine motor skills can be difficult, and Annabelle's hands sometimes have involuntary jerks and tremors when doing fine motor work (despite physical and occupational therapy). Given this and her memory and processing deficits, her psychologist recommended that she be allowed extra time to complete assignments, a quiet environment when doing work that requires focus, and/or for her to type assignments or use a scribe as needed. That said, Deerstream classes, by nature of their structure and environment, have always organically supported these needs. Furthermore, most of Annabelle's solo "focus work" for this class will be done at home, geometry won't require extended periods of hand writing, and Mrs Hall has taught Annabelle in classes before, so I don't anticipate a need for specific accommodations while she is at Deerstream. |
| Insurance | |
| Name of Policy Holder | Stephen Edwards |
| Employer | RTI |
| Insurance Company | Cigna |
| Policy Number | U6591603204 |
| 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 | Lauralea Edwards |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
