| Student's Name | Nora Grace McCall |
|---|---|
| Date Of Birth | 07/01/2011 |
| T shirt size | Women's Cut S |
| PARENT INFORMATION | |
| Parent 1 | Emily McCall |
| Cell Phone | (630) 301-9368 |
| Home/Work Phone | (630) 301-9368 |
| Parent 2 | Paul McCall |
| Cell Phone | (321) 438-8077 |
| Emergency Contact 1 | Amy MacDonald |
| Relationship | neighbor |
| Phone Number | (207) 939-2527 |
| Emergency Contact 2 | Harriet Orstad |
| Relationship | neighbor |
| Phone Number | (919) 619-8621 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Alcaraz |
| Physician's Phone Number | 9196812020 |
| Current Medications and Dosages | none |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | none |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Paul McCall |
| Employer | Oracle |
| Insurance Company | United Healthcare |
| Policy Number | 9358322203 |
| 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 | Emily McCall |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
