| Student's Name | Arabella Wilk |
|---|---|
| Date Of Birth | 12/10/2014 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Jared Wilk |
| Cell Phone | (919) 638-9380 |
| Home/Work Phone | (919) 638-9296 |
| 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 | Friend |
| Phone Number | (919) 641-1984 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Silkstone |
| Physician's Phone Number | 9199424173 |
| Current Medications and Dosages | None |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Arabella Wilk |
| Employer | N/A |
| Insurance Company | United Healthcare |
| Policy Number | 953834293N |
| 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
