| Student's Name | Eleanor Ruby Swing |
|---|---|
| Date Of Birth | 06/26/2012 |
| T shirt size | Adult Unisex S |
| PARENT INFORMATION | |
| Parent 1 | Trista Swing |
| Cell Phone | (910) 262-6259 |
| Home/Work Phone | (910) 262-6259 |
| Parent 2 | Timothy Swing |
| Cell Phone | (910) 228-6342 |
| Home/Work Phone | (919) 636-9717 |
| Emergency Contact 1 | Crystal West |
| Relationship | Friend |
| Phone Number | (919) 302-6276 |
| Emergency Contact 2 | Kathryn Eriksen |
| Relationship | Friend |
| Phone Number | (919) 923-6363 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | Yes |
| If yes, please name the allergy/allergies. |
|
| 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. | Slight. Reaction: Itchy mouth. Can be given Benadryl to stop. |
| Please describe the warning signs or symptoms of an allergic reaction. | Itchy mouth |
| In case of allergic reaction, please describe exactly what steps we should take. | Give Benadryl |
| Does this child carry Benadryl or an epipen? | no |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Cory Annis |
| Physician's Phone Number | (919)914-9611 |
| Preferred Medical Facility | UNC |
| Current Medications and Dosages | None |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | 2020: Diagnosed with ocular migraines. |
| Will your child need the learning environment or assignments adapted in any way? | Yes |
| If so, please describe. | I am checking with the Vision Therapist for an updated adaptations list, if any. |
| What other information will help us to provide a safe and accessible environment for your child? | Eleanor is taking vision therapy for eye tracking/eye teaming problems, as well as some visual processing issues. The recommendations from above were given before she began therapy, and may not be needed at this point. I have emailed the doctor for an update on her status. |
| Insurance | |
| Name of Policy Holder | Timothy Swing |
| Employer | Parkway family Dentistry |
| Insurance Company | BlueCross BlueShield |
| Policy Number | Y2K104687797 |
| 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 | Trista Swing |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
