| Student's Name | Ellie Harris |
|---|---|
| Date Of Birth | 03/15/2014 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Michelle Harris |
| Cell Phone | (919) 368-4070 |
| Home/Work Phone | (919) 368-4080 |
| Parent 2 | Jason Harris |
| Cell Phone | (919) 433-7786 |
| Emergency Contact 1 | Kay Harris |
| Relationship | Grandmother |
| Phone Number | (561) 160-1991 |
| Emergency Contact 2 | Rick Harris |
| Relationship | Grandfather |
| Phone Number | (561) 827-5950 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Ray Clark |
| Physician's Phone Number | 919-220-4000 |
| Preferred Medical Facility | Duke |
| Current Medications and Dosages | None |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | ADHD |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Jason Harris |
| Employer | Precision BioScience |
| Insurance Company | BCBS |
| Policy Number | Yps102947588 |
| 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 | Michelle Harris |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
