Deerstream

Student's Name	Tyler Downs
Date Of Birth	05/26/2011
T shirt size	Child L
PARENT INFORMATION
Parent 1	Emily Downs
Cell Phone	(252) 723-3717
Home/Work Phone	(252) 723-3717
Parent 2	Timothy Downs
Cell Phone	(252) 725-0289
Home/Work Phone	(252) 725-0289
Emergency Contact 1	Kisa Jackson
Relationship	friend
Phone Number	(919) 724-7353
Emergency Contact 2	Louise Mason
Relationship	grandmother
Phone Number	(704) 281-7991
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Joseph Wehby
Physician's Phone Number	919-361-2644
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	Timothy Downs
Employer	Thomas and Hutton
Insurance Company	Cigna
Policy Number	990510709
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	Emily Downs
Signature