T-shirt size

Student's Name	Olivia G Helgevold
Date Of Birth	05/10/2018
T shirt size	Child XS
PARENT INFORMATION
Parent 1	Kelly Helgevold
Cell Phone	(901) 484-2906
Home/Work Phone	(901) 484-2906
Parent 2	Ethan Helgevold
Cell Phone	(919) 880-6951
Emergency Contact 1	Charles Helgevold
Relationship	Grandfather
Phone Number	(919) 417-3496
Emergency Contact 2	Anna Moore
Relationship	Aunt
Phone Number	(919) 428-3739
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Vines
Physician's Phone Number	919-245-3247
Preferred Medical Facility	UNC Hospital
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	Ethan Helgevold
Employer	Self employed
Insurance Company	Christian Healthcare Ministries
Policy Number	N/A we pay all costs upfront and if applicable our insurance will reimburse.
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	Kelly Helgevold
Signature