| Student's Name | Maddox James Matthews |
|---|---|
| Date Of Birth | 03/31/2018 |
| T shirt size | Child XS |
| PARENT INFORMATION | |
| Parent 1 | Courtney Matthews |
| Cell Phone | (910) 890-2801 |
| Home/Work Phone | (910) 890-2801 |
| Parent 2 | Trent Matthews |
| Cell Phone | (910) 616-0362 |
| Home/Work Phone | (910) 616-0362 |
| Emergency Contact 1 | Debbie Williamson |
| Relationship | grandparent |
| Phone Number | (910) 658-3731 |
| Emergency Contact 2 | Ashley Morris |
| Relationship | nanny |
| Phone Number | (336) 459-6854 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Joseph Jackson |
| Physician's Phone Number | 9196205333 |
| Preferred Medical Facility | Duke Hospital |
| Current Medications and Dosages | n/a |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | 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? | n/a |
| Insurance | |
| Name of Policy Holder | Trent Matthews |
| Employer | Clever, Inc. |
| Insurance Company | Anthem BCBS |
| Policy Number | XDP456W05553 |
| 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 | Courtney Matthews |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
