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Student's NameCecelia Rose Briscoe
Date Of Birth04/15/2017
T shirt sizeChild S
PARENT INFORMATION
Parent 1Amanda Briscoe
Cell Phone(304) 488-3968
Home/Work Phone(304) 488-3968
Parent 2Joshua Briscoe
Cell Phone(304) 376-7863
Emergency Contact 1Amanda Briscoe
Relationshipmother
Phone Number(304) 488-3968
Emergency Contact 2RiLee Robeson
Relationshipfriend/godparent
Phone Number(719) 659-9867
ALLERGY INFORMATION
Does this child have any known allergies?No
OTHER MEDICAL INFORMATION
Physician's NameDr. John Moses
Physician's Phone Number919-620-5333
Preferred Medical FacilityDuke
Current Medications and Dosages

none

Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.

Cecelia occasionally will break out in hives when she is over-heated or outdoors a lot. (We haven't been able to nail down the exact cause). If it is noticed or she complains about it, just let me know and I can give her some Zyrtec (or leave some there for her if that is allowed).

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?

Cecelia LOVES Deerstream and is extroverted and loves making friends and her teachers!

Insurance
Name of Policy HolderJoshua Briscoe
EmployerDurham VA
Insurance CompanyBlue Cross Blue Shield
Policy NumberR61160773
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.
NameAmanda Briscoe
Signature