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Student's NameNoah Zachary Maximillian Goetz
Date Of Birth07/09/2010
T shirt sizeAdult Unisex S
PARENT INFORMATION
Parent 1Nathaniel Goetz
Cell Phone(919) 451-9637
Home/Work Phone(919) 451-9637
Parent 2Parul Patel
Cell Phone(919) 451-7154
Home/Work Phone(919) 451-7154
Emergency Contact 1Amanda Perez
RelationshipFamily Friend
Phone Number(919) 523-5998
Emergency Contact 2Christina John
RelationshipFamily Friend
Phone Number(732) 668-2314
ALLERGY INFORMATION
Does this child have any known allergies?Yes
If yes, please name the allergy/allergies.
  • Mild seasonal allergies - pollen
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.

Spring time mild seasonal allergies - some sneezing.

Please describe the warning signs or symptoms of an allergic reaction.

N/A

In case of allergic reaction, please describe exactly what steps we should take.

N/A

Does this child carry Benadryl or an epipen?no
OTHER MEDICAL INFORMATION
Physician's NameKellie Ferin
Physician's Phone Number919-933-8381
Preferred Medical FacilityUNC
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
Insurance
Name of Policy HolderParul Patel
EmployerGSK
Insurance Companyaetna
Policy NumberW4605-45517
SIGNATUREI, 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.
NameNathaniel Goetz
Signature