| Student's Name | Elle Claire Barton |
|---|---|
| Date Of Birth | 01/07/2015 |
| T shirt size | Child M |
| PARENT INFORMATION | |
| Parent 1 | Elizabeth Barton |
| Cell Phone | (316) 304-9471 |
| Home/Work Phone | (316) 304-9471 |
| Parent 2 | Casey Barton |
| Cell Phone | (316) 304-9381 |
| Emergency Contact 1 | Elizabeth Barton |
| Relationship | Mom |
| Phone Number | (316) 304-9471 |
| Emergency Contact 2 | Grace Allen |
| Relationship | Nanny |
| Phone Number | (740) 629-7744 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Laura Windham |
| Physician's Phone Number | 9199670771 |
| 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 | Elizabeth Barton |
| Employer | UNC |
| Insurance Company | State Health Plan |
| Policy Number | YPY104473481 |
| 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 | Elizabeth Barton |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
