Deerstream

Student's Name	Christopher Willard Patten
Date Of Birth	07/29/2017
T shirt size	Child XS
PARENT INFORMATION
Parent 1	Aaron Patten
Cell Phone	(512) 517-7804
Home/Work Phone	(984) 439-8169
Parent 2	Winston Patten
Cell Phone	(919) 917-8965
Emergency Contact 1	Sara Patten
Relationship	Mother
Phone Number	(512) 517-7804
Emergency Contact 2	Aaron Patten
Relationship	Father
Phone Number	(919) 917-8965
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Edward Pickens
Physician's Phone Number	919 806-3335
Preferred Medical Facility	Southpoint Pediatrics
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	Aaron Patten
Employer	Nebulon
Insurance Company	Anthem Blue Cross
Policy Number	YSQ774M87497
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	Sara Patten
Signature