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Student's NameMahlon Daniel Barton
Date Of Birth04/17/2012
T shirt sizeChild L
PARENT INFORMATION
Parent 1Elizabeth Barton
Cell Phone(316) 304-9471
Home/Work Phone(316) 304-9471
Parent 2Casey Barton
Cell Phone(316) 304-9381
Emergency Contact 1Elizabeth Barton
RelationshipMom
Phone Number(316) 304-9471
Emergency Contact 2Grace Allen
RelationshipNanny
Phone Number(740) 629-7744
ALLERGY INFORMATION
Does this child have any known allergies?No
OTHER MEDICAL INFORMATION
Physician's NameLaura Windham
Physician's Phone Number9199670771
Preferred Medical FacilityUNC
Current Medications and Dosages

none

Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.

ADHD
Dysgraphia

Will your child need the learning environment or assignments adapted in any way?Yes
If so, please describe.

Nothing new, but would benefit from option to dictate or verbalize responses when appropriate, decreased volume of written work when able. Making improvements over time.

What other information will help us to provide a safe and accessible environment for your child?

Deerstream has done a marvelous job accommodating for Mahlon to be successful and we are forever grateful!! Thank you!

Insurance
Name of Policy HolderElizabeth Barton
EmployerUNC
Insurance CompanyState Health Plan
Policy NumberYPY104473481
SIGNATUREI, 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.
NameElizabeth Barton
Signature