Deerstream

Student's Name	Elena Grace Syfrett
Date Of Birth	06/05/2008
T shirt size	Adult Unisex S
PARENT INFORMATION
Parent 1	Adena Syfrett
Cell Phone	(919) 423-7707
Home/Work Phone	(919) 806-3827
Parent 2	Eric Syfrett
Cell Phone	(919) 605-7715
Emergency Contact 1	Jessica Jones
Relationship	Friend
Phone Number	(919) 619-2486
Emergency Contact 2	Kisa Jackson
Relationship	Friend
Phone Number	(919) 724-7353
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Thomas Marsland
Physician's Phone Number	9193612644
Preferred Medical Facility	UNC
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	Eric Syfrett
Employer	Kings Park International Church
Insurance Company	BCBS
Policy Number	YPS103502998
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	Adena Syfrett
Signature