| Student's Name | Owen Edward Rentzke |
|---|---|
| Date Of Birth | 05/28/2016 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Mary (Call me Katie) Rentzke |
| Cell Phone | (650) 622-6280 |
| Home/Work Phone | (650) 622-6280 |
| Parent 2 | Anton Craig Rentzke |
| Cell Phone | (650) 335-8999 |
| Emergency Contact 1 | Mary (Call me Katie) Rentzke |
| Relationship | mom |
| Phone Number | (650) 622-6280 |
| Emergency Contact 2 | Cindy Johnson |
| Relationship | aunt |
| Phone Number | (937) 239-6643 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Robinson |
| Physician's Phone Number | 919-942-4173 |
| Preferred Medical Facility | chapel Hill Pediactrics |
| Current Medications and Dosages | none |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Owen has a sensory processing disorder. If he gets overwhelmed or frustrated by a situation, please remove him from the situation, have him take deep breaths, and give him something manipulative to play with. Possible give him a snack. If need be process the situation and talk him through the situation. |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Anton Craig Rentzke |
| Employer | Fidelity Investments |
| Insurance Company | UMR |
| Policy Number | 28320206 |
| 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 | Mary Katherine Rentzke |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
