T-shirt size

Student's Name	Kate Conway
Date Of Birth	04/29/2010
T shirt size	Women's Cut M
PARENT INFORMATION
Parent 1	Anikke Conway
Cell Phone	(919) 224-9956
Home/Work Phone	(919) 224-9956
Emergency Contact 1	Benjamin Conway
Relationship	Father
Phone Number	(919) 886-3740
Emergency Contact 2	Irene Rodriguez
Relationship	Neighbor
Phone Number	(919) 972-1483
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Lisa ferrari
Physician's Phone Number	9192204000
Preferred Medical Facility	Duke
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	Benjamin Conway
Employer	Duke
Insurance Company	Aetna
Policy Number	W231733403
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	Anikke Conway
Signature