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Student's NameOscar Herrick Chafin
Date Of Birth08/08/2016
T shirt sizeChild S
PARENT INFORMATION
Parent 1Jill Chafin
Cell Phone(919) 259-2687
Home/Work Phone(919) 259-2687
Parent 2Cliff Chafin
Cell Phone(919) 357-3255
Emergency Contact 1Lisa Hess
RelationshipFamily friend
Phone Number(919) 265-4381
Emergency Contact 2Lauren Lindbald
RelationshipFamily friend
Phone Number(919) 929-7685
ALLERGY INFORMATION
Does this child have any known allergies?No
OTHER MEDICAL INFORMATION
Physician's NameMichael Minozzi
Physician's Phone Number(919) 967-0771
Preferred Medical FacilityChapel Hill Children's Clinic
Current Medications and Dosages

Miralax (once a week)
Pedialax (every day)

Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.

Oscar has encopresis from long-term constipation. He takes Miralax and Pedialax on a regular basis and this issue is mostly under control. It helps if he has time to sit on the toilet for about 5 minutes after lunch (but he's pretty good at remembering to do this himself). He will occasionally have bathroom accidents when he's very constipated but he is capable of handling the clean-up on his own.

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?

Oscar has a sensitivity to gluten so please avoid giving him gluten treats and snacks.
He also has a hard time with competitive games and will run away to have "alone time" if he loses.

Insurance
Name of Policy HolderOscar Chafin
EmployerN/A
Insurance CompanyHealthyBlue
Policy NumberGJN728052695
SIGNATUREI, 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.
NameJill Chafin
Signature