Deerstream

Student's Name	Charles Eric Lynch
Date Of Birth	07/25/2016
T shirt size	Child M
PARENT INFORMATION
Parent 1	Jean Lynch
Cell Phone	(919) 768-2105
Home/Work Phone	(919) 768-2105
Parent 2	Griffin Lynch
Cell Phone	(919) 308-7364
Emergency Contact 1	Clarissa Bacon
Relationship	Grandmother
Phone Number	(919) 697-1706
Emergency Contact 2	Bob Bacon
Relationship	Grandfather
Phone Number	(336) 621-2528
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Martha Snyder
Physician's Phone Number	(919) 620-5333
Preferred Medical Facility	Duke Childrens Primary Care
Current Medications and Dosages	N/a
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?	Non
Insurance
Name of Policy Holder	Griffin Lynch
Employer	Ferguson
Insurance Company	Blue Cross and Blue Shield
Policy Number	Fzxan8432654
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	Jean Lynch
Signature