| Student's Name | Alberto Juan Tarajano |
|---|---|
| Date Of Birth | 06/15/2012 |
| T shirt size | Child L |
| PARENT INFORMATION | |
| Parent 1 | Alberto Tarajano |
| Cell Phone | (225) 806-2983 |
| Home/Work Phone | (225) 806-2983 |
| Parent 2 | Meredith Tarajano |
| Cell Phone | (225) 975-9056 |
| Emergency Contact 1 | Alberto Tarajano |
| Relationship | Father |
| Phone Number | (225) 806-2983 |
| Emergency Contact 2 | Meredith Tarajano |
| Relationship | Mother |
| Phone Number | (225) 985-9056 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | Yes |
| If yes, please name the allergy/allergies. |
|
| Please describe the situation and severity of the allergy. For instance, some children are allergic to egg but can eat eggs in baked goods, while others have a sensitivity to the presence of the allergen in the environment. | Berto can have a life threatening reaction to these items. Berto also has Asthma |
| Please describe the warning signs or symptoms of an allergic reaction. | Itchy. Hives. Shortness of breath. |
| In case of allergic reaction, please describe exactly what steps we should take. | Inject with epi pen. |
| Does this child carry Benadryl or an epipen? | yes |
| What is it and where will it be located? (In the lunchbox, in the front pocket of the bookbag, etc.). What is the dosage and indication for the medicine? Can your child self-administer or will he need help? (In general, we don't allow teachers to administer medications except in emergency situations.) | Book bag |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Chapel Hill Pediatrics |
| Physician's Phone Number | 9199424173 |
| Preferred Medical Facility | Duke |
| Current Medications and Dosages | Asthma as needed |
| Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received. | Asthma. Berto has been diagnosed with ADHD |
| 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? | None |
| Insurance | |
| Name of Policy Holder | Alberto Tarajano |
| Employer | Pala Group |
| Insurance Company | UMR |
| Policy Number | 29874822 member ID |
| 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 | Alberto Tarajano |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
