Deerstream

Student's Name	Asher Johnson
Date Of Birth	05/29/2011
T shirt size	Child L
PARENT INFORMATION
Parent 1	Andrea Coachman
Cell Phone	(919) 454-1267
Home/Work Phone	(919) 454-1267
Parent 2	Lewayde Johnson
Cell Phone	(919) 823-8899
Emergency Contact 1	Steve Shaffer
Relationship	Friend
Phone Number	(919) 606-1561
Emergency Contact 2	Herman Coachman
Relationship	Grandfather
Phone Number	(256) 525-1801
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Clark
Physician's Phone Number	9192204000
Preferred Medical Facility	Unc
Current Medications and Dosages	None
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Andrea Coachman
Employer	Unc hospitals
Insurance Company	Blue cross blue shield
Policy Number	Ypy104600411
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	Andrea Coachman
Signature