T-shirt size

Student's Name	Elinor Sophia Fisher
Date Of Birth	05/15/2012
T shirt size	Child XL
PARENT INFORMATION
Parent 1	Martina Fisher
Cell Phone	(336) 380-8288
Home/Work Phone	(336) 380-8288
Parent 2	Nathaniel Fisher
Cell Phone	(561) 866-5920
Emergency Contact 1	Susan Fisher
Relationship	Grandmother
Phone Number	(336) 214-4397
Emergency Contact 2	Donna Simeone
Relationship	Grandmother
Phone Number	(561) 451-1752
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Lynne Morgan
Physician's Phone Number	984-215-4339
Preferred Medical Facility	UNC
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
Insurance
Name of Policy Holder	Nathaniel Fisher
Employer	Konica Minolta/ All Covered
Insurance Company	Cigna
Policy Number	U4667746003
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	Martina Fisher
Signature