T-shirt size

Student's Name	Lydia Jade Nola EBERT
Date Of Birth	10/17/2016
T shirt size	Child S
PARENT INFORMATION
Parent 1	Deborah Ebert
Cell Phone	(419) 202-8742
Home/Work Phone	(419) 202-8742
Parent 2	Aaron Ebert
Cell Phone	(419) 515-2071
Emergency Contact 1	Cory Pikaart
Relationship	Friend
Phone Number	(330) 554-2987
Emergency Contact 2	Rebecca Devine
Relationship	Friend
Phone Number	(623) 670-0324
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Elizabeth Erickson
Physician's Phone Number	9196205333
Preferred Medical Facility	Duke Regional Hospital
Current Medications and Dosages	Nil
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	Nil
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Lydia Ebert
Employer	N/A
Insurance Company	Healthy Blue (Medicaid)
Policy Number	954697436Q
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	Deborah Ebert
Signature