| Student's Name | Joseph Michael Wright Coppit |
|---|---|
| Date Of Birth | 09/09/2009 |
| T shirt size | Adult Unisex XL |
| PARENT INFORMATION | |
| Parent 1 | Dorothy Coppit |
| Cell Phone | (919) 886-0798 |
| Home/Work Phone | (919) 886-0798 |
| Parent 2 | David Coppit |
| Cell Phone | (919) 806-7558 |
| Home/Work Phone | (919) 806-7558 |
| Emergency Contact 1 | Julie Brown |
| Relationship | Close friend and neighbor |
| Phone Number | (919) 564-6072 |
| Emergency Contact 2 | Mike Detweiller |
| Relationship | Close friend and neighbor |
| Phone Number | (210) 872-9611 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | Yes |
| If yes, please name the allergy/allergies. |
|
| Please describe the situation and severity of the allergy. For instance, some children are allergic to egg but can eat eggs in baked goods, while others have a sensitivity to the presence of the allergen in the environment. | His allergies to nuts and shrimp are mild. The reaction is NOT life threatening, but it causes discomfort and swelling. Being around the foods is totally fine. If he eats them by mistake, he will be ok. |
| Please describe the warning signs or symptoms of an allergic reaction. | throat discomfort (nuts) lips swelling (shrimp) |
| In case of allergic reaction, please describe exactly what steps we should take. | He should be ok, just drink lots of water to help his throat discomfort with nuts |
| Does this child carry Benadryl or an epipen? | no |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Joseph Jackson |
| Physician's Phone Number | 919 620 5333 |
| Preferred Medical Facility | Any UNC facility |
| Current Medications and Dosages | Prozac, 30 mg. Claritin, once daily |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Diagnosed as being on the spectrum for Autism |
| 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? | He thrives at Deerstream! You all do a fantastic job already! I can not think of anything to add. |
| Insurance | |
| Name of Policy Holder | David Coppit |
| Employer | self |
| Insurance Company | Blue Cross/ Blue Shield |
| Policy Number | Y2K104633850 |
| 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 | Dorothy Coppit |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
