Deerstream

Student's Name	Felix Noel Becker
Date Of Birth	07/13/2012
T shirt size	Child M
PARENT INFORMATION
Parent 1	Mary Becker
Cell Phone	(310) 486-0713
Home/Work Phone	(310) 486-0713
Parent 2	Jeff Becker
Cell Phone	(949) 422-5639
Home/Work Phone	(949) 422-5639
Emergency Contact 1	Cristina Starr
Relationship	friend
Phone Number	(919) 961-2684
Emergency Contact 2	Molly Scalise
Relationship	grandmother
Phone Number	(805) 636-3018
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Robert Sears
Preferred Medical Facility	n/a
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	switching over at the moment-will update when I know n/a
Employer	Moms Across America/Primary Color
Insurance Company	n/a
Policy Number	n/a (switching over with new job)
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	Mary Becker
Signature