| Student's Name | Audrey Meitl |
|---|---|
| Date Of Birth | 05/18/2011 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Rachel Meitl |
| Cell Phone | (919) 607-7224 |
| Home/Work Phone | (919) 607-7224 |
| Parent 2 | Matthew Meitl |
| Cell Phone | (217) 377-3755 |
| Emergency Contact 1 | Rachel Meitl |
| Relationship | Mother |
| Phone Number | (919) 607-7224 |
| Emergency Contact 2 | Matt Meitl |
| Relationship | Father |
| Phone Number | (217) 377-3755 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Dr. Murray |
| Physician's Phone Number | (919) 544-2049 |
| Preferred Medical Facility | Regional Pediatrics or Duke |
| Current Medications and Dosages | None |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Matt Meitl |
| Employer | XDC |
| Insurance Company | Blue Cross Blue Shield |
| Policy Number | 14162911 |
| 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 | Rachel Meitl |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
