| Student's Name | Miriam Calais Van Farowe |
|---|---|
| Date Of Birth | 02/06/2008 |
| T shirt size | Adult Unisex S |
| PARENT INFORMATION | |
| Parent 1 | Roxanne VanFarowe |
| Cell Phone | (919) 448-1912 |
| Home/Work Phone | (919) 260-5100 |
| Parent 2 | James VanFarowe |
| Cell Phone | (984) 260-5100 |
| Emergency Contact 1 | Sara Patten |
| Relationship | Friend |
| Phone Number | (512) 517-7804 |
| Emergency Contact 2 | Sarah Coonley |
| Relationship | Friend |
| Phone Number | (919) 308-1865 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Duke Children’s Primarily Care |
| Physician's Phone Number | 9196305333 |
| Preferred Medical Facility | Duke |
| Current Medications and Dosages | Jone |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | James VanFarowe |
| Employer | Duke University Medical Center |
| Insurance Company | Aetna Duke Basic |
| Policy Number | W236870888 |
| 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 | Roxanne VanFarowe |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
