Deerstream

Student's Name	Callie Whitenack
Date Of Birth	03/21/2017
T shirt size	Child XS
PARENT INFORMATION
Parent 1	Joy Whitenack
Cell Phone	(984) 244-8720
Home/Work Phone	(984) 244-8720
Parent 2	Caleb Whitenack
Cell Phone	(984) 244-8834
Emergency Contact 1	Rachael Fuchs
Relationship	Sister/Aunt
Phone Number	(972) 439-8214
Emergency Contact 2	Kelly Pettigrew
Relationship	Friend
Phone Number	(919) 265-4402
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Mary Cooley
Physician's Phone Number	+1 (919) 942-4173
Preferred Medical Facility	Chapel Hill Pediatrics
Current Medications and Dosages	None
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	None
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?	None
Insurance
Name of Policy Holder	Caleb Whitenack
Employer	Animo Sano Psychiatry
Insurance Company	Cigna
Policy Number	18332913 01
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	Joy Whitenack
Signature