| Student's Name | Vanessa Wan-Ying Yu |
|---|---|
| Date Of Birth | 02/26/2014 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Lisa Yu |
| Cell Phone | (919) 699-2820 |
| Home/Work Phone | (919) 699-2820 |
| Parent 2 | Sunny yu |
| Cell Phone | (919) 806-7957 |
| Emergency Contact 1 | David Millington |
| Relationship | Grandfather |
| Phone Number | (919) 448-8221 |
| Emergency Contact 2 | Savannah YU |
| Relationship | Adult sister |
| Phone Number | (919) 748-8782 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | durham pediatrics |
| Physician's Phone Number | 919-220-4000 |
| Preferred Medical Facility | duke university |
| Current Medications and Dosages | none |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Vanessa Yu |
| Employer | self |
| Insurance Company | medicaid |
| Policy Number | 9532997831 |
| 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 | Lisa Yu |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
