| Student's Name | Quinn McGraw |
|---|---|
| Date Of Birth | 07/02/2018 |
| T shirt size | Child XS |
| PARENT INFORMATION | |
| Parent 1 | Kelly Mcgraw |
| Cell Phone | (831) 277-5869 |
| Home/Work Phone | (831) 277-5869 |
| Parent 2 | Andrew Mcgraw |
| Cell Phone | (607) 351-9052 |
| Emergency Contact 1 | Brittany Chamberlain |
| Relationship | Friend |
| Phone Number | (865) 414-0687 |
| Emergency Contact 2 | Amy Thomas |
| Relationship | Friend |
| Phone Number | (919) 407-9122 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Preferred Medical Facility | Duke 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? | Quinn seems to thrive on routine/consistency and can struggle when that is disrupted. Talking through how things are going to vary from a set routine can be helpful. |
| Insurance | |
| Name of Policy Holder | Andrew McGraw |
| Employer | Duke University Hospital |
| Insurance Company | Aetna |
| Policy Number | 285535-010-00001 |
| 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 | Kelly Mcgraw |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
