Deerstream

Student's Name	Eric David Richards
Date Of Birth	07/18/2019
T shirt size	Child S
PARENT INFORMATION
Parent 1	Theresa Richards
Cell Phone	(919) 593-8018
Home/Work Phone	(919) 593-8018
Parent 2	Robert Richards
Cell Phone	(919) 593-8346
Emergency Contact 1	Susan Boyd
Relationship	Grandma
Phone Number	(661) 583-6318
Emergency Contact 2	Mary Ann Richards
Relationship	Grandma
Phone Number	(954) 325-4569
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Barbara Bergdolt
Physician's Phone Number	9842155900
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	Robert Richards
Employer	Milliman
Insurance Company	Regence BlueShield
Policy Number	M3M201116194
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	Theresa Richards
Signature