T-shirt size

Student's Name	Connor Liu
Date Of Birth	07/10/2017
T shirt size	Child S
PARENT INFORMATION
Parent 1	Hung-Yi Liu
Cell Phone	(646) 678-9553
Home/Work Phone	(646) 678-9553
Parent 2	Ching-Wen Tan
Cell Phone	(646) 678-9580
Emergency Contact 1	Ching-Wen Tan
Relationship	Mother
Phone Number	(646) 678-9580
Emergency Contact 2	Hung-Yi Liu
Relationship	Father
Phone Number	(646) 678-9553
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
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	Hung-Yi Liu
Employer	Motivo, Inc.
Insurance Company	United Healthcare
Policy Number	986996942
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	Hung-Yi Liu
Signature