Deerstream

Student's Name	Olivia yu
Date Of Birth	01/01/2008
T shirt size	Adult Unisex L
PARENT INFORMATION
Parent 1	Lisa Yu
Cell Phone	(191) 969-9282
Home/Work Phone	(919) 699-2820
Parent 2	Sunny yu
Cell Phone	(919) 806-7957
Emergency Contact 1	David Millington
Relationship	grand father
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	Dr Clark durham peds
Physician's Phone Number	9192204000
Preferred Medical Facility	duke university
Current Medications and Dosages	none
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
Insurance
Name of Policy Holder	olivia yu
Employer	none
Insurance Company	wellcare
Policy Number	31952280
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