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Student's NameJoseph Caspian Ransom
Date Of Birth07/05/2012
T shirt sizeChild L
PARENT INFORMATION
Parent 1Ashley Ransom
Cell Phone(919) 592-5557
Home/Work Phone(919) 592-5552
Parent 2Gifford Ransom
Cell Phone(919) 594-9433
Home/Work Phone(919) 594-9433
Emergency Contact 1Ashley Ransom
Relationshipmother
Phone Number(919) 592-5557
Emergency Contact 2Giff Ransom
Relationshipfather
Phone Number(919) 594-9433
ALLERGY INFORMATION
Does this child have any known allergies?Yes
If yes, please name the allergy/allergies.
  • penicillin
Please describe the situation and severity of the allergy. For instance, some children are allergic to egg but can eat eggs in baked goods, while others have a sensitivity to the presence of the allergen in the environment.

fine as long as you aren't giving him antibiotics 😉

Please describe the warning signs or symptoms of an allergic reaction.

hives, shortness of breath

Does this child carry Benadryl or an epipen?no
OTHER MEDICAL INFORMATION
Physician's NameMeri Harper
Physician's Phone Number919-967-0771
Preferred Medical FacilityUNC
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 HolderAshley Ransom
Employernone
Insurance Companycash pay
Policy Numbernone
SIGNATUREI, 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.
NameAshley Ransom
Signature