| Student's Name | Hyrum Painchaud |
|---|---|
| Date Of Birth | 07/06/2010 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Miki Sunguza |
| Cell Phone | (202) 823-6007 |
| Home/Work Phone | (202) 823-6007 |
| Parent 2 | Israel Painchaud |
| Cell Phone | (703) 574-0373 |
| Home/Work Phone | (703) 574-0373 |
| Emergency Contact 1 | Natacha Sunguza |
| Relationship | Aunt |
| Phone Number | (450) 238-1112 |
| Emergency Contact 2 | Gareth Cooper |
| Relationship | Uncle |
| Phone Number | (705) 360-3173 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | No physician |
| Physician's Phone Number | n/a |
| Preferred Medical Facility | n/a |
| Current Medications and Dosages | no medication |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Dislexia |
| Will your child need the learning environment or assignments adapted in any way? | Yes |
| If so, please describe. | Instructions need to be demonstrated. Otherwise he will ask and repeat questions to ensure he has understood properly. |
| What other information will help us to provide a safe and accessible environment for your child? | Due to his dyslexia, we have gone slowly on his reading experience to ensure he doesn't learn to hate it. He is still very enthusiast about reading but might read a little slower than the average. His writing does suffer a little from this as well and he is aware of it. We do want him to get comfortable with this and he does have tutors for this, but it might be a little uncomfortable at reading in front of the whole class. |
| Insurance | |
| Name of Policy Holder | Israel Painchaud |
| Employer | Aira Corp |
| Insurance Company | Anthem |
| Policy Number | JQU915W15585 |
| 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 | Israel Painchaud |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
