| Student's Name | Emilia (Millie) Grace Thompson |
|---|---|
| Date Of Birth | 10/17/2015 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Kristen Thompson |
| Cell Phone | (919) 922-4301 |
| Home/Work Phone | (919) 922-4301 |
| Parent 2 | Scott Thompson |
| Cell Phone | (919) 920-6226 |
| Home/Work Phone | (919) 920-6226 |
| Emergency Contact 1 | Kelly Pettigrew |
| Relationship | Friend |
| Phone Number | (919) 265-4402 |
| Emergency Contact 2 | Malcolm Pettigrew |
| Relationship | Friend |
| Phone Number | (919) 265-4688 |
| 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. | She's only had it once and broke out in a full body rash. Doctors advised we discontinue and not use it again in the future. |
| Please describe the warning signs or symptoms of an allergic reaction. | Rash |
| In case of allergic reaction, please describe exactly what steps we should take. | Medical attention |
| Does this child carry Benadryl or an epipen? | no |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr Laura Andrews / Carrboro Peds |
| Physician's Phone Number | 9199338381 |
| Preferred Medical Facility | Duke |
| Current Medications and Dosages | N/A |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | N/A |
| 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? | N/A |
| Insurance | |
| Name of Policy Holder | Scott Thompson |
| Employer | Duke |
| Insurance Company | Aetna |
| Policy Number | 285535-010-00001 / ID W2317 41041 |
| 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 | Kristen Thompson |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
