| Student's Name | Avery Jane Chleboun |
|---|---|
| Date Of Birth | 02/24/2016 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Kimberly Chleboun |
| Cell Phone | (330) 204-3081 |
| Home/Work Phone | (330) 204-3081 |
| Parent 2 | Jon Chleboun |
| Cell Phone | (740) 591-9393 |
| Home/Work Phone | (229) 316-1481 |
| Emergency Contact 1 | Laura Rosenberg |
| Relationship | Aunt |
| Phone Number | (925) 787-2737 |
| Emergency Contact 2 | Mary Chleboun |
| Relationship | grandmother |
| Phone Number | (740) 592-2001 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Durham Pediatrics |
| Physician's Phone Number | 9192204000 |
| Preferred Medical Facility | Duke |
| Current Medications and Dosages | none |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Avery has vasovagal syncope - simply stated, she sometimes passes out. Her trigger seems to be discussing bodily functions, wounds, first aid care... etc. This is not a routine thing, it's very rare for this to happen, but thought I should mention it. She's aware of this, and may let you know if she's feeling ill. |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Jon Chleboun |
| Employer | Nextiva |
| Insurance Company | Cigna |
| Policy Number | U83286208 03 |
| 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 | Kimberly Chleboun |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
