| Student's Name | Micah Samwise Elniff |
|---|---|
| Date Of Birth | 09/15/2016 |
| T shirt size | Child S |
| PARENT INFORMATION | |
| Parent 1 | Sarah Elniff |
| Cell Phone | (919) 589-4455 |
| Home/Work Phone | (919) 589-4455 |
| Parent 2 | Sam Elniff |
| Cell Phone | (919) 309-5151 |
| Emergency Contact 1 | Kathryn Robertson |
| Relationship | Micah's grandmother |
| Phone Number | (336) 270-1113 |
| Emergency Contact 2 | Abby Hummel |
| Relationship | friend |
| Phone Number | (515) 509-3857 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Stephanie Sussman |
| Physician's Phone Number | 984-215-4339 |
| 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. | Developmental delays in sensory processing, fine motor, and self regulation. |
| Will your child need the learning environment or assignments adapted in any way? | Yes |
| If so, please describe. | I am not sure yet, his IEP paperwork through the school system is not yet complete. He did not have any formal adaptations last year. |
| What other information will help us to provide a safe and accessible environment for your child? | Micah loves being at Deerstream. He loves stories and he loves hands on activities. He is very eager and curious to learn. He feels more comfortable if he can take his time with a task. He will get overwhelmed, as a number of things are challenging for him including fine motor tasks like writing. Loud or really bright environments can be overwhelming to him, but he might not show distress in the moment. We are working on things that he can do himself to cope in these situations. |
| Insurance | |
| Name of Policy Holder | Micah Elniff |
| Employer | none |
| Insurance Company | Carolina Complete Health |
| Policy Number | 954686717T |
| 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 | Sarah Elniff |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
