T-shirt size

Student's Name	Penny Ruth Thomas
Date Of Birth	10/09/2013
T shirt size	Child L
PARENT INFORMATION
Parent 1	Amy Thomas
Cell Phone	(919) 407-9122
Home/Work Phone	(919) 407-9122
Parent 2	Justin Thomas
Cell Phone	(919) 407-9244
Emergency Contact 1	Jen Posey
Relationship	Friend
Phone Number	(919) 357-4505
Emergency Contact 2	Kayla Willis
Relationship	Aunt
Phone Number	(540) 598-1843
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Dr Bolden
Physician's Phone Number	+1 (919) 813-2539
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
What other information will help us to provide a safe and accessible environment for your child?	Nothing in addition to what you are already doing 🙂
Insurance
Name of Policy Holder	Justin Thomas
Employer	Dooable Health
Insurance Company	Samaritan Ministries
Policy Number	Self pay
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	Amy Thomas
Signature