| Student's Name | Iona Jane Batchelor |
|---|---|
| Date Of Birth | 01/18/2012 |
| T shirt size | Child L |
| PARENT INFORMATION | |
| Parent 1 | Andrew Batchelor |
| Cell Phone | (919) 213-7704 |
| Home/Work Phone | (984) 259-8298 |
| Parent 2 | Polly Ha |
| Cell Phone | (919) 213-7705 |
| Emergency Contact 1 | Claire Atkins |
| Relationship | Friend |
| Phone Number | (919) 236-9901 |
| Emergency Contact 2 | Rachel Culbertson |
| Relationship | Friend |
| Phone Number | (206) 491-3160 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Kathleen Murphy |
| Physician's Phone Number | 919-328-3852 |
| Preferred Medical Facility | Durham Pediatrics |
| 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 |
| What other information will help us to provide a safe and accessible environment for your child? | Nothing of note. |
| Insurance | |
| Name of Policy Holder | Polly Ha |
| Employer | Duke University |
| Insurance Company | Duke Aetna |
| Policy Number | W267566880 |
| 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 | Andrew Batchelor |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
