Deerstream

Student's Name	Eloise Williams
Date Of Birth	02/10/2014
T shirt size	Child M
PARENT INFORMATION
Parent 1	Elizabeth Williams
Cell Phone	(919) 619-1337
Home/Work Phone	(919) 568-0314
Parent 2	Ryan Williams
Cell Phone	(336) 269-0236
Home/Work Phone	(336) 269-0236
Emergency Contact 1	Anna Johnsen
Relationship	Friend
Phone Number	(919) 454-6966
Emergency Contact 2	Judy Williams
Relationship	Grandmother
Phone Number	(336) 269-0236
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Deanna Branscom
Physician's Phone Number	9199338381
Preferred Medical Facility	UNC Hospitals
Current Medications and Dosages	None
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Ryan Williams
Employer	SWECO
Insurance Company	BCBS
Policy Number	YPS104892165
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	Elizabeth Williams
Signature