Deerstream

Student's Name	Samuel Wise Doyal
Date Of Birth	02/07/2023
T shirt size	Child XL
PARENT INFORMATION
Parent 1	Alice Doyal
Cell Phone	(540) 820-7812
Home/Work Phone	(540) 820-7812
Parent 2	Alexander Doyal
Cell Phone	(540) 820-7820
Emergency Contact 1	Ray Toher
Relationship	Grandfather
Phone Number	(919) 699-3583
Emergency Contact 2	Caroline Daniels
Relationship	Aunt
Phone Number	(706) 540-7400
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Moore
Physician's Phone Number	9849740210
Preferred Medical Facility	UNC
Current Medications and Dosages	Vyvanse 20mg
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	ADHD
Will your child need the learning environment or assignments adapted in any way?	Yes
If so, please describe.	Sam has dyslexia, so spelling is difficult for him.
Insurance
Name of Policy Holder	Alexander Doyal
Employer	UNC
Insurance Company	BCBS State Health Plan
Policy Number	YPY104460453
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	Alice Doyal
Signature