| Student's Name | Sophia Mailys Tellier |
|---|---|
| Date Of Birth | 06/23/2011 |
| T shirt size | Adult Unisex S |
| PARENT INFORMATION | |
| Parent 1 | Maia Tellier |
| Cell Phone | (919) 357-0882 |
| Home/Work Phone | (919) 960-0386 |
| Emergency Contact 1 | Nicolette Schwartzman |
| Relationship | Grandmother |
| Phone Number | (919) 357-0877 |
| Emergency Contact 2 | Jessica Schwartzman |
| Relationship | Aunt |
| Phone Number | (919) 357-0880 |
| 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. | Hives! And bananas was swelling of face |
| Please describe the warning signs or symptoms of an allergic reaction. | Hives |
| In case of allergic reaction, please describe exactly what steps we should take. | Contact us |
| Does this child carry Benadryl or an epipen? | no |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr vines |
| Physician's Phone Number | 9192453247 |
| Preferred Medical Facility | Unc |
| Current Medications and Dosages | None |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Dystonia |
| Will your child need the learning environment or assignments adapted in any way? | Yes |
| If so, please describe. | Can’t run well and can have tired fingers from writing |
| Insurance | |
| Name of Policy Holder | Sophia Tellier |
| Employer | None |
| Insurance Company | Can’t remember it is in USA! |
| Policy Number | 123456 |
| 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 | Maia Tellier |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
