| Student's Name | Clara Mae Allen |
|---|---|
| Date Of Birth | 03/22/2018 |
| T shirt size | Child S |
| PARENT INFORMATION | |
| Parent 1 | Grace Allen |
| Cell Phone | (740) 629-7744 |
| Home/Work Phone | (740) 629-7744 |
| Parent 2 | Justin(Wyatt) Allen |
| Cell Phone | (304) 991-8264 |
| Emergency Contact 1 | Betsy Allen |
| Relationship | Grandmother |
| Phone Number | (304) 991-0686 |
| Emergency Contact 2 | Ana Dence |
| Relationship | Friend |
| Phone Number | (951) 973-1366 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Village Pediatrics |
| Physician's Phone Number | 9199699611 |
| Current Medications and Dosages | N/A |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Justin Allen |
| Employer | Coastal Federal Credit Union |
| Insurance Company | United Healthcare |
| Policy Number | 989114827 |
| 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 | Grace Allen |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
