T-shirt size

Student's Name	Zahra Painchaud
Date Of Birth	12/14/2014
T shirt size	Child S
PARENT INFORMATION
Parent 1	Miki Sunguza
Cell Phone	(202) 823-6007
Home/Work Phone	(202) 823-6007
Parent 2	Israel Painchaud
Cell Phone	(703) 574-0373
Home/Work Phone	(703) 574-0373
Emergency Contact 1	Natacha Sunguza
Relationship	Aunt
Phone Number	(450) 238-1112
Emergency Contact 2	Gareth Cooper
Relationship	Uncle
Phone Number	(705) 360-3173
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	n/a
Physician's Phone Number	n/a
Preferred Medical Facility	n/a
Current Medications and Dosages	n/a
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Israel Painchaud
Employer	Aira Corp
Insurance Company	Anthem
Policy Number	JQU915W15585
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	Israel Painchaud
Signature