T-shirt size

Student's Name	Jack Stephen Eriksen
Date Of Birth	11/05/2012
T shirt size	Child M
PARENT INFORMATION
Parent 1	Kathryn Eriksen
Cell Phone	(919) 923-6363
Home/Work Phone	(919) 923-6363
Parent 2	Rusty Eriksen
Cell Phone	(919) 923-6604
Emergency Contact 1	Trista Swing
Relationship	Friend
Phone Number	(910) 262-6259
Emergency Contact 2	Jeanette White
Relationship	Friend
Phone Number	(864) 506-5921
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Jessie prestwood
Physician's Phone Number	984-215-5900
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.	None
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Russell Eriksen
Employer	Hilltop wealth advisors
Insurance Company	Blue cross blue shield
Policy Number	Yps103948348
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	Kathryn Eriksen
Signature