| Student's Name | Brody Wilk |
|---|---|
| Date Of Birth | 03/04/2013 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Jared Wilk |
| Cell Phone | (919) 638-9380 |
| Home/Work Phone | (919) 638-9380 |
| Parent 2 | Freya Wilk |
| Cell Phone | (919) 638-9296 |
| Emergency Contact 1 | Karen Kuhlmann |
| Relationship | Nana |
| Phone Number | (919) 536-9121 |
| Emergency Contact 2 | Erin Crossfield |
| Relationship | Family friend |
| Phone Number | (919) 641-1984 |
| 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. | It’s mild. He will break out in hives if given penicillin. |
| Does this child carry Benadryl or an epipen? | no |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Silkstone |
| Physician's Phone Number | 9199424173 |
| Preferred Medical Facility | Chapel Hill Pediatrics or Duke |
| Current Medications and Dosages | None |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Brody Wilk |
| Employer | N/A |
| Insurance Company | United Health Care |
| Policy Number | 952850656T |
| 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 | Freya Wilk |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
