T-shirt size

Student's Name	Natalie Meiferdt
Date Of Birth	07/03/2008
T shirt size	Women's Cut M
PARENT INFORMATION
Parent 1	Chris Meiferdt
Cell Phone	(919) 491-8252
Home/Work Phone	(919) 286-0411
Parent 2	Sisleide Meiferdt
Cell Phone	(919) 491-8936
Home/Work Phone	(919) 491-8936
Emergency Contact 1	Cecilia Romascanu
Relationship	Friend
Phone Number	(919) 471-6271
Emergency Contact 2	Caroline Quartier Smith
Relationship	Friend
Phone Number	(919) 824-2426
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dain Vines
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?	Nothing special
Insurance
Name of Policy Holder	Christopher Meiferdt
Employer	Durham VA
Insurance Company	Blue Cross Blue Shield
Policy Number	R60513339
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	Christopher Meiferdt
Signature