T-shirt size

Student's Name	Samuel Matthew Joseph
Date Of Birth	07/14/2016
T shirt size	Child M
PARENT INFORMATION
Parent 1	Allison Joseph
Cell Phone	(540) 419-0957
Home/Work Phone	(540) 419-0957
Parent 2	Matthew Joseph
Cell Phone	(813) 778-2857
Emergency Contact 1	Allison Joseph
Relationship	Mother
Phone Number	(540) 419-0957
Emergency Contact 2	Matthew Joseph
Relationship	Father
Phone Number	(813) 778-2857
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Walker Robinson, MD
Physician's Phone Number	919-942-4173
Preferred Medical Facility	UNC or Duke
Current Medications and Dosages	None
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Matthew Joseph
Employer	Billerud
Insurance Company	Anthem BCBS
Policy Number	V3R624W16477
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	Allison Joseph
Signature