| Student's Name | Gwyneth Signy Martin |
|---|---|
| Date Of Birth | 07/01/2013 |
| T shirt size | Child XL |
| PARENT INFORMATION | |
| Parent 1 | Linda Martin |
| Cell Phone | (919) 923-1955 |
| Home/Work Phone | (919) 923-1955 |
| Parent 2 | Steven Martin |
| Cell Phone | (919) 985-1139 |
| Emergency Contact 1 | Michele Martin |
| Relationship | Grandma |
| Phone Number | (919) 370-1423 |
| Emergency Contact 2 | Devin Martin |
| Relationship | Older brother |
| Phone Number | (919) 923-6464 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Sussman |
| Physician's Phone Number | (984) 215-4339 |
| Preferred Medical Facility | UNC Pediatrics at Weaver Crossing |
| Current Medications and Dosages | None |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Steven Martin |
| Employer | JRBLM |
| Insurance Company | Blue Cross Blue Shield |
| Policy Number | Y2K102231184 |
| 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 | Linda Martin |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
