T-shirt size

Student's Name	Brian Godwin Curry
Date Of Birth	03/08/2008
T shirt size	Adult Unisex M
PARENT INFORMATION
Parent 1	Brian Curry
Cell Phone	(314) 517-4811
Home/Work Phone	(314) 517-4811
Parent 2	Andrea Curry
Cell Phone	(314) 283-3039
Emergency Contact 1	Virginia Barth
Relationship	grandmother - I'm assuming you're looking for a third-priority phone number in case of not being able to get parents.
Phone Number	(757) 784-0278
Emergency Contact 2	Alexa Gerend
Relationship	family friend
Phone Number	(919) 452-6883
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Michael Minozzi
Physician's Phone Number	919-967-0771
Preferred Medical Facility	Any UNC
Current Medications and Dosages	none
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Brian Curry
Employer	self-employed
Insurance Company	Blue Cross Blue Shield
Policy Number	Y2K102836630
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	Andrea Curry
Signature