| Student's Name | Anna Michelle Cook |
|---|---|
| Date Of Birth | 02/15/2013 |
| T shirt size | Child L |
| PARENT INFORMATION | |
| Parent 1 | Megan Cook |
| Cell Phone | (413) 663-4882 |
| Home/Work Phone | (413) 663-4882 |
| Parent 2 | John Cook |
| Cell Phone | (910) 584-7393 |
| Home/Work Phone | (910) 584-7393 |
| Emergency Contact 1 | Rachel Buttle |
| Relationship | Family Friend |
| Phone Number | (330) 550-1273 |
| Emergency Contact 2 | Elysia Kjeka |
| Relationship | Family Friend |
| Phone Number | (919) 842-1188 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Sarah Ruff |
| Physician's Phone Number | 9193612644 |
| Current Medications and Dosages | none |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | John Cook |
| Employer | Duke University Hospital |
| Insurance Company | BCBS |
| Policy Number | - |
| 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 | Megan Cook |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
