T-shirt size

Student's Name	Oliver Canyon Cecil
Date Of Birth	03/22/2018
T shirt size	Child S
PARENT INFORMATION
Parent 1	Bonne Cecil
Cell Phone	(770) 862-7583
Home/Work Phone	(770) 862-7583
Parent 2	Kyle Cecil
Cell Phone	(757) 243-4877
Home/Work Phone	(757) 243-4877
Emergency Contact 1	Kristen Thompson
Relationship	friend
Phone Number	(919) 922-4301
Emergency Contact 2	Leslie Stone
Relationship	friend
Phone Number	(770) 906-8578
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Lindsey Fiacco
Physician's Phone Number	(919) 679-9511
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.	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?	N/A
Insurance
Name of Policy Holder	Aaron Cecil
Employer	Duke Hospital
Insurance Company	Aetna Duke Select
Policy Number	W267403065
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	Bonne Cecil
Signature