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Student's NameMabel Jubilee Swing
Date Of Birth10/15/2014
T shirt sizeChild M
PARENT INFORMATION
Parent 1Trista Swing
Cell Phone(910) 262-6259
Home/Work Phone(910) 262-6259
Parent 2Timothy Swing
Cell Phone(910) 228-6342
Home/Work Phone(929) 636-9717
Emergency Contact 1Trista Swing
Relationshipmother
Phone Number(910) 262-6259
Emergency Contact 2Timothy Swing
Relationshipfather
Phone Number(919) 514-1632
ALLERGY INFORMATION
Does this child have any known allergies?Yes
If yes, please name the allergy/allergies.
  • dustmite
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.

This is an environmental allergy that shouldn't have much effect on Mabel at school. Typically dustmites are in mattresses, sheets and pillows. Her allergy presents as nasal drainage and itchy/watery eyes. It is not severe and can be treated with an allergy pill.

Please describe the warning signs or symptoms of an allergic reaction.

N/A

In case of allergic reaction, please describe exactly what steps we should take.

Contact me.

Does this child carry Benadryl or an epipen?no
OTHER MEDICAL INFORMATION
Physician's NameDr. Cory Annis
Physician's Phone Number9195141632
Preferred Medical FacilityUNC
Current Medications and Dosages

Mabel periodically takes a child's 24-hour Zyrtec.

Will your child need the learning environment or assignments adapted in any way?No
Insurance
Name of Policy HolderTimothy Swing
EmployerParkway Dental
Insurance CompanyBlueCross BlueShield
Policy NumberY2K104687797
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.
NameTrista Swing
Signature