T-shirt size

Student's Name	Logan Anthony Schmidt
Date Of Birth	07/20/2017
T shirt size	Child XS
PARENT INFORMATION
Parent 1	Anna Schmidt
Cell Phone	(919) 619-5394
Home/Work Phone	(919) 619-5394
Parent 2	Trevor Schmidt
Cell Phone	(919) 619-5393
Home/Work Phone	(919) 619-5393
Emergency Contact 1	Stacy Green
Relationship	Friend
Phone Number	(919) 900-0956
Emergency Contact 2	Jennifer Norris
Relationship	Friend
Phone Number	(919) 358-6577
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Kirsche
Physician's Phone Number	919-806-3335
Preferred Medical Facility	UNC
Current Medications and Dosages	Adderall, 1 pill xaily
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	ADHD
Will your child need the learning environment or assignments adapted in any way?	No
What other information will help us to provide a safe and accessible environment for your child?	None
Insurance
Name of Policy Holder	Logan Schmidt
Employer	N/A
Insurance Company	Medicaid
Policy Number	954910508N
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	Anna Schmidt
Signature