| Student's Name | Adelaide Yvonne Cunningham |
|---|---|
| Date Of Birth | 06/13/2017 |
| T shirt size | Child S |
| PARENT INFORMATION | |
| Parent 1 | Neile Cunningham |
| Cell Phone | (828) 216-2052 |
| Home/Work Phone | (828) 216-2052 |
| Parent 2 | Dylan Cunningham |
| Cell Phone | (828) 337-6149 |
| Home/Work Phone | (828) 337-6149 |
| Emergency Contact 1 | Neile Cunningham |
| Relationship | Mother |
| Phone Number | (828) 216-2052 |
| Emergency Contact 2 | Dylan Cunningham |
| Relationship | Father |
| Phone Number | (828) 337-6149 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | Yes |
| If yes, please name the allergy/allergies. |
|
| 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. | Breaks out in hives and swelling if a dog licks her. She is also EXTREMELY terrified of any dog in sight because of her allergy. |
| Please describe the warning signs or symptoms of an allergic reaction. | hives, facial swelling |
| In case of allergic reaction, please describe exactly what steps we should take. | childrens benedryl, no longer have epi pen ( had when she had food allergies but she has outgrown them now) |
| Does this child carry Benadryl or an epipen? | no |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Western Wake Wellness |
| Physician's Phone Number | 919-378-1492 |
| Current Medications and Dosages | none |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | did have food allergies to dairy and egg but has been cleared and has outgrown allergy over the past two years. |
| Will your child need the learning environment or assignments adapted in any way? | No |
| What other information will help us to provide a safe and accessible environment for your child? | no animal visit days. haha she is so scared of animals because of her allergy. |
| Insurance | |
| Name of Policy Holder | none none |
| Employer | none |
| Insurance Company | none |
| Policy Number | none |
| 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 | Neile Cunningham |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
