Deerstream

Student's Name	Wesley Culbertson
Date Of Birth	01/09/2014
T shirt size	Child M
PARENT INFORMATION
Parent 1	Rachel Culbertson
Cell Phone	(206) 491-3160
Home/Work Phone	(206) 491-3160
Parent 2	Sterling Culbertson
Cell Phone	(425) 444-8944
Home/Work Phone	(425) 444-8944
Emergency Contact 1	Alexa Carter
Relationship	Family Friend
Phone Number	(919) 452-4754
Emergency Contact 2	Bethany Porter
Relationship	Family Friend
Phone Number	(567) 203-7499
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Joanne Band
Physician's Phone Number	919-620-5333
Preferred Medical Facility	Duke Pediatrics South Durham
Current Medications and Dosages	none
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Sterling Culbertson
Employer	Duke Healthcare Systems
Insurance Company	Aetna
Policy Number	W237459845
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	Rachel Culbertson
Signature