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Student's NameColin Christopher Bingham
Date Of Birth05/13/2012
T shirt sizeChild L
PARENT INFORMATION
Parent 1Kelli Bingham
Cell Phone(508) 561-5177
Home/Work Phone(508) 561-5177
Parent 2Chris Bingham
Cell Phone(617) 447-4659
Home/Work Phone(617) 447-4659
Emergency Contact 1Kevin Ohrenberger
RelationshipGrandparent
Phone Number(812) 360-2250
Emergency Contact 2Karen Ohrenberger
RelationshipGrandparent
Phone Number(203) 581-0240
ALLERGY INFORMATION
Does this child have any known allergies?Yes
If yes, please name the allergy/allergies.
  • Penicillin
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.

Mild severity-skin reaction/hives

Does this child carry Benadryl or an epipen?no
OTHER MEDICAL INFORMATION
Physician's NameDuke Primary Care Hillsborough - LeAnn Owens
Physician's Phone Number919-813-6367
Preferred Medical FacilityDuke
Current Medications and Dosages

Concerta - 28 mg

Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.

ADHD, dysgraphia

Will your child need the learning environment or assignments adapted in any way?No
Insurance
Name of Policy HolderChristopher Bingham
EmployerDuke University
Insurance CompanyDuke Select/Aetna
Policy NumberW247513741
SIGNATUREI, 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.
NameKelli Bingham
Signature