| Student's Name | Noelle Elizabeth Burleson |
|---|---|
| Date Of Birth | 01/07/2014 |
| T shirt size | Child L |
| PARENT INFORMATION | |
| Parent 1 | Elizabeth Burleson |
| Cell Phone | (919) 264-6862 |
| Home/Work Phone | (919) 264-6862 |
| Parent 2 | W. Scott Burleson |
| Cell Phone | (919) 607-2391 |
| Home/Work Phone | (919) 607-2391 |
| Emergency Contact 1 | Audrey Burleson |
| Relationship | Aunt |
| Phone Number | (919) 895-0671 |
| Emergency Contact 2 | Liza Bradford |
| Relationship | Grandmother |
| Phone Number | (804) 855-8171 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr Christine Lehrich |
| Physician's Phone Number | 919-852-0177 |
| 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. | n/a |
| 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? | Noelle is a kind and sweet child - she loves to have fun and is excited to meet and make new friends! |
| Insurance | |
| Name of Policy Holder | W. Scott Burleson |
| Employer | AIM Institute |
| Insurance Company | MediShare |
| Policy Number | 07178B72100 |
| 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 | Elizabeth Burleson |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
