| Student's Name | Andrew Edward Williams |
|---|---|
| Date Of Birth | 10/15/2014 |
| T shirt size | Child M |
| 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? | 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. | Andy is anaphylactic to peanut and sesame. He has oral desensitization to coconut and avocado (they make his mouth itch) and he can have egg in baked goods. |
| Please describe the warning signs or symptoms of an allergic reaction. | Andy's reactions tend to be GI related, meaning pain in abdomen and vomiting. |
| In case of allergic reaction, please describe exactly what steps we should take. | In the event of a mild exposure Andy should be given 10mL of Zyrtec (kept in his backpack). Should a serious reaction occur his Auvi-Q auto injector (also kept in his backpack) should be used and 911 should be dialed with the request for an ambulance with epinephrine. After the injector has been administer he should be laid on his back with his legs kept above his heart to help circulate the medicine. If symptoms continue to increase in severity while waiting for an ambulance a second injector should be given after 5-10 minutes of the first injection. |
| Does this child carry Benadryl or an epipen? | yes |
| What is it and where will it be located? (In the lunchbox, in the front pocket of the bookbag, etc.). What is the dosage and indication for the medicine? Can your child self-administer or will he need help? (In general, we don't allow teachers to administer medications except in emergency situations.) | Andy will have Zyrtec and his 2 Auvi-Q auto injectors, along with a trainer, in the small front zipped pocket of his backpack (the one where his name is). |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Laura Andrews |
| Physician's Phone Number | 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? | Andy tends to be reserved and quite at first, but he is very determined and loves a challenge. |
| Insurance | |
| Name of Policy Holder | William Williams |
| Employer | BioAgilytix Labs |
| 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
