Deerstream

Student's Name	Harrison E Ebert
Date Of Birth	10/10/2014
T shirt size	Child M
PARENT INFORMATION
Parent 1	Martha Blankenship Ebert
Cell Phone	(919) 923-1631
Home/Work Phone	(919) 923-1631
Emergency Contact 1	Jamie Ebert
Relationship	Dad
Phone Number	(919) 519-4788
Emergency Contact 2	Brooklyn Blankenship
Relationship	Aunt
Phone Number	(479) 208-1438
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Unc Pieds
Physician's Phone Number	919-966-6669
Preferred Medical Facility	UNC
Current Medications and Dosages	N/A
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Jamie Ebert
Employer	Sysco
Insurance Company	Aetna
Policy Number	W2700 07723
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	Martha Blankenship Ebert
Signature