| Student's Name | Hannah Grace Toilolo |
|---|---|
| Date Of Birth | 03/07/2017 |
| T shirt size | Child S |
| PARENT INFORMATION | |
| Parent 1 | Meghann Toilolo |
| Cell Phone | (404) 304-1229 |
| Home/Work Phone | (404) 304-1229 |
| Parent 2 | Tifi Toilolo |
| Cell Phone | (404) 664-7559 |
| Home/Work Phone | (404) 664-7559 |
| Emergency Contact 1 | Barbara McParlan |
| Relationship | Maternal Grandmother |
| Phone Number | (734) 645-3090 |
| Emergency Contact 2 | Thomas McParlan |
| Relationship | Maternal Grandfather |
| Phone Number | (984) 281-5300 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Kathleen Murphy NP |
| Physician's Phone Number | 9192204000 |
| Preferred Medical Facility | Duke Children's Hospital |
| 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 |
| What other information will help us to provide a safe and accessible environment for your child? | Hannah cannot hear out of her left ear; please let her sit in the front of the class. |
| Insurance | |
| Name of Policy Holder | Tifi Toilolo |
| Employer | Duke University Hospital |
| Insurance Company | Aetna Duke Select |
| Policy Number | ID :W231574594 |
| 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 | Meghann Toilolo |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
