| Student's Name | Benjamin Thomas Williams |
|---|---|
| Date Of Birth | 01/11/2013 |
| T shirt size | Child L |
| PARENT INFORMATION | |
| Parent 1 | Kate Williams |
| Cell Phone | (910) 398-4294 |
| Home/Work Phone | (910) 398-4294 |
| Parent 2 | Will Williams |
| Cell Phone | (910) 603-2538 |
| Home/Work Phone | (919) 694-2839 |
| Emergency Contact 1 | Rhonda Higgins |
| Relationship | Grandma |
| Phone Number | (910) 795-8843 |
| Emergency Contact 2 | Carol Eubanks |
| Relationship | Family friend |
| Phone Number | (336) 676-2446 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Laura Andrews |
| Physician's Phone Number | +1 (919) 933-8381 |
| Preferred Medical Facility | UNC Hospital |
| Current Medications and Dosages | N/A |
| 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? | Ben is very reserved and timid in new class settings, he tends to take some time to warm up. Also, he can get nervous when asked to speak in front of the class (present) and he can get anxious/frustrated when he is unsure of what is expected of him. |
| Insurance | |
| Name of Policy Holder | William Williams |
| Employer | BioAgilytix |
| Insurance Company | BlueCross BlueShield |
| Policy Number | RDU102942416 Group#: 14159969 |
| 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 | Katherine Williams |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
