T-shirt size

Student's Name	Stephanie Paige Curry
Date Of Birth	08/20/2008
T shirt size	Adult Unisex M
PARENT INFORMATION
Parent 1	Kerry Curry
Cell Phone	(336) 264-2431
Home/Work Phone	(336) 264-2431
Parent 2	Denise Curry
Cell Phone	(336) 213-2880
Emergency Contact 1	Randy Ayscue
Relationship	Uncle
Phone Number	(336) 516-7094
Emergency Contact 2	Christine Ayscue
Relationship	Aunt
Phone Number	(336) 263-2433
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Kristen Page
Physician's Phone Number	336-228-8316
Preferred Medical Facility	UNC Hillsborough
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
What other information will help us to provide a safe and accessible environment for your child?	None
Insurance
Name of Policy Holder	Kerry Curry
Employer	Labcorp
Insurance Company	Cigna
Policy Number	3329799
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	Denise Curry
Signature