T-shirt size

Student's Name	Grace Rose Iboaya
Date Of Birth	09/24/2013
T shirt size	Child L
PARENT INFORMATION
Parent 1	Karen Iboaya
Cell Phone	(803) 237-3212
Home/Work Phone	(803) 237-3212
Parent 2	Ehimemen Iboaya
Cell Phone	(336) 831-6380
Home/Work Phone	(336) 831-6380
Emergency Contact 1	Sylvia Iboaya
Relationship	Aunt
Phone Number	(816) 517-4651
Emergency Contact 2	Itua Iboaya
Relationship	Uncle
Phone Number	(816) 682-4067
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr. Silstone at Chapel Hill Pediatrics
Physician's Phone Number	919-942-4173
Preferred Medical Facility	Duke Hospital
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	Ehimemen Iboaya
Employer	Duke Hospital
Insurance Company	Blue Cross
Policy Number	DKH103670740
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	Karen Iboaaya
Signature