T-shirt size

Student's Name	Daniel James Upshaw
Date Of Birth	09/02/2016
T shirt size	Child S
PARENT INFORMATION
Parent 1	Ben Upshaw
Cell Phone	(919) 949-4689
Home/Work Phone	(919) 949-4689
Parent 2	Stephanie Upshaw
Cell Phone	(919) 268-0198
Home/Work Phone	(919) 268-0198
Emergency Contact 1	Stephanie Upshaw
Relationship	mother
Phone Number	(919) 268-0198
Emergency Contact 2	Ben Upshaw
Relationship	father
Phone Number	(919) 949-4689
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Wang
Physician's Phone Number	919-477-2202
Preferred Medical Facility	Duke
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	Benjamin Upshaw
Employer	NCDOT
Insurance Company	Blue Cross Blue Shield
Policy Number	YPY104542290
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	Stephanie Upshaw
Signature