Deerstream

Student's Name	Sophie - Skromovas San Miguel
Date Of Birth	02/14/2012
T shirt size	Child L
PARENT INFORMATION
Parent 1	Andrea Skromovas
Cell Phone	(954) 562-6702
Home/Work Phone	(000) 000-0000
Parent 2	Fabio San Miguel Millan
Cell Phone	(954) 562-5756
Emergency Contact 1	Fernanda Monteiro
Relationship	Friend
Phone Number	(954) 258-1090
Emergency Contact 2	Anna Johnsen
Relationship	Friend
Phone Number	(919) 454-6966
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Kimberly Kylstra
Physician's Phone Number	984 215 5900
Current Medications and Dosages	No medications
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Fabio San Miguel millan
Employer	Microsoft
Insurance Company	Blue Cross Blue Shield
Policy Number	MSJ 601131335 02
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	Andrea Skromovas
Signature