| Student's Name | Sarah Grace Spiel |
|---|---|
| Date Of Birth | 04/09/2014 |
| T shirt size | Adult Unisex S |
| PARENT INFORMATION | |
| Parent 1 | Adam Spiel |
| Cell Phone | (559) 267-8082 |
| Home/Work Phone | (559) 267-8082 |
| Parent 2 | Annie Spiel |
| Cell Phone | (559) 940-8363 |
| Emergency Contact 1 | Heather Spiel |
| Relationship | aunt |
| Phone Number | (989) 600-9773 |
| Emergency Contact 2 | Steven Spiel |
| Relationship | uncle |
| Phone Number | (312) 730-4859 |
| 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 cannot eat anything with nuts, peas, pistachios, lentils. Other people around her can have nuts - she is not sensitive to the presence of the allergen in the environment - only if she ingests them or puts them in her mouth. She knows to avoid them. She also has a mild allergy with pet dander |
| Please describe the warning signs or symptoms of an allergic reaction. | mild: hard to swallow or discomfort in throat moderate: vomiting severe: difficulty breathing |
| In case of allergic reaction, please describe exactly what steps we should take. | first take benadryl - 1 x 25mg if reaction is moderate and she has vomited 1 time then give her another benadryl 1x25mg if reaction is severe and she has vomited more than 1 time or is having difficulty breathing - then administer 1 dose of epipen. |
| Does this child carry Benadryl or an epipen? | yes |
| What is it and where will it be located? (In the lunchbox, in the front pocket of the bookbag, etc.). What is the dosage and indication for the medicine? Can your child self-administer or will he need help? (In general, we don't allow teachers to administer medications except in emergency situations.) | in her backpack front pocket. She can administer benadryl. 1 benadryl pill of 25mg. She usually is able to manage her own symptoms with benadryl alone. She cannot administer epipen. 1 Epipen is a single dose. We have never had to administer an epipen with Sarah (yet) |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Shruti Nagaraj, |
| Physician's Phone Number | 919.942.4173 |
| Preferred Medical Facility | Chapel Hill Pediatrics or UNC urgent care |
| Current Medications and Dosages | epipen |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Dyslexia diagnosis |
| Will your child need the learning environment or assignments adapted in any way? | Yes |
| If so, please describe. | may need assignments read to her or help with reading |
| Insurance | |
| Name of Policy Holder | Adam Spiel |
| Employer | Self employed |
| Insurance Company | Healthy Blue |
| Policy Number | GJN731103144 |
| 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 | Adam Spiel |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
