T-shirt size

Student's Name	Felix Zhou
Date Of Birth	12/01/2011
T shirt size	Child L
PARENT INFORMATION
Parent 1	Biao Zhou
Cell Phone	(408) 891-1930
Home/Work Phone	(408) 891-1930
Parent 2	Xiaoshan Fang
Cell Phone	(919) 208-8968
Home/Work Phone	(919) 208-8968
Emergency Contact 1	Yunjun Mu
Relationship	Neighbor
Phone Number	(919) 449-5750
Emergency Contact 2	Ming Li
Relationship	Neighbor
Phone Number	(919) 724-2603
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Min Zhao
Physician's Phone Number	9193633427
Preferred Medical Facility	UNC
Current Medications and Dosages	None
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
What other information will help us to provide a safe and accessible environment for your child?	N/A
Insurance
Name of Policy Holder	Biao Zhou
Employer	Self Employeed
Insurance Company	USHealth Group
Policy Number	78-800132
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	Biao Zhou
Signature