T-shirt size

Student's Name	Helen Pauline Swafford
Date Of Birth	12/22/2009
T shirt size	Women's Cut M
PARENT INFORMATION
Parent 1	Susan Swafford
Cell Phone	(919) 395-9960
Home/Work Phone	(919) 395-9960
Parent 2	Brian Swafford
Cell Phone	(480) 243-6764
Emergency Contact 1	Susan Swafford
Relationship	mother
Phone Number	(919) 395-9960
Emergency Contact 2	Brian Swafford
Relationship	father
Phone Number	(480) 243-6764
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Amy Fowler
Physician's Phone Number	919 967 0771
Preferred Medical Facility	Duke
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
Insurance
Name of Policy Holder	Brian Swafford
Employer	WL Gore and Associates
Insurance Company	Highmark BCBS
Policy Number	WLZ108883795001
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	Susan Swafford
Signature