| Student's Name | Sonnet Carter |
|---|---|
| Date Of Birth | 10/08/2009 |
| T shirt size | Women's Cut S |
| PARENT INFORMATION | |
| Parent 1 | Alexa Carter |
| Cell Phone | (919) 452-4754 |
| Home/Work Phone | (919) 452-4754 |
| Emergency Contact 1 | Daniel Carter |
| Relationship | father |
| Phone Number | (919) 638-1364 |
| Emergency Contact 2 | Levi Mason |
| Relationship | uncle |
| Phone Number | (704) 607-1895 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Eunee Park |
| Physician's Phone Number | (919) 806-3335 |
| Preferred Medical Facility | We're happy with either Duke or UNC, whichever is easier or more convenient |
| Current Medications and Dosages | none |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Sonnet had a knee surgery almost two years ago - it's mostly recovered, but we still see the physical therapist since it sometimes still flares up. Sonnet can take care of herself with that, though. |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Daniel Carter |
| Employer | NC DOT |
| Insurance Company | Blue Cross Blue Shield |
| Policy Number | YPY104553669 |
| 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 | Alexa Carter |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
