T-shirt size

Student's Name	Adelaide Chlair White
Date Of Birth	05/03/2016
T shirt size	Child M
PARENT INFORMATION
Parent 1	Renee White
Cell Phone	(919) 539-1424
Home/Work Phone	(919) 539-1424
Parent 2	James White
Cell Phone	(347) 813-6711
Home/Work Phone	(919) 932-3220
Emergency Contact 1	Robert Connolly
Relationship	grandfather
Phone Number	(919) 259-5724
Emergency Contact 2	Cindy Connolly
Relationship	grandmother
Phone Number	(919) 259-5728
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Lindsey Fiacco
Physician's Phone Number	9193852030
Preferred Medical Facility	Duke Sage Road Pediatrics
Current Medications and Dosages	n/a
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	n/a
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Renee White
Employer	Local Government Federal Credit Union
Insurance Company	BCBS
Policy Number	yps10488755200
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	Renee White
Signature