T-shirt size

Student's Name	Levi Emerson Zeller
Date Of Birth	04/05/2017
T shirt size	Child S
PARENT INFORMATION
Parent 1	Caitlyn Zeller
Cell Phone	(704) 322-5258
Home/Work Phone	(704) 322-5258
Parent 2	Tyler Zeller
Cell Phone	(812) 698-7790
Home/Work Phone	(812) 698-7790
Emergency Contact 1	Caitlyn Zeller
Relationship	Mother
Phone Number	(704) 322-5258
Emergency Contact 2	Joe Ferebee
Relationship	Grandfather
Phone Number	(704) 699-2286
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Kim Kylstra
Physician's Phone Number	9842155900
Preferred Medical Facility	North Chatham Pediatrics and Internal Medicine
Current Medications and Dosages	None
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	Just occasional nosebleeds
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Tyler Zeller
Employer	NBA Retiree Program
Insurance Company	United Healthcare
Policy Number	911-87726-04
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	Caitlyn Zeller
Signature