T-shirt size

Student's Name	Cameron Edward Bryant
Date Of Birth	12/13/2012
T shirt size	Adult Unisex S
PARENT INFORMATION
Parent 1	Al Bryant
Cell Phone	(919) 937-7283
Home/Work Phone	(919) 937-7283
Parent 2	Sabrina Bryant
Cell Phone	(919) 308-7179
Home/Work Phone	(919) 308-7189
Emergency Contact 1	Terri Jennette Harris
Relationship	grandmother
Phone Number	(919) 345-3283
Emergency Contact 2	Rafique Harris
Relationship	step grandfather
Phone Number	(984) 365-2728
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	James M Troutman, MD
Physician's Phone Number	919-525-3630
Preferred Medical Facility	Durham Pediatrics at North Duke Street
Current Medications and Dosages	N/A
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Al Bryant
Employer	Cisco Systems
Insurance Company	United Health Care
Policy Number	946136643
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	Sabrina Bryant
Signature