| Student's Name | Imogen Grace Curry |
|---|---|
| Date Of Birth | 02/02/2010 |
| T shirt size | Adult Unisex S |
| PARENT INFORMATION | |
| Parent 1 | Brian Curry |
| Cell Phone | (314) 517-4811 |
| Home/Work Phone | (314) 517-4811 |
| Parent 2 | Andrea Curry |
| Cell Phone | (984) 291-9183 |
| Home/Work Phone | (314) 283-3039 |
| Emergency Contact 1 | Virginia Barth |
| Relationship | grandmother |
| Phone Number | (757) 784-0278 |
| Emergency Contact 2 | Jack Peterson |
| Relationship | Uncle |
| Phone Number | (757) 903-7814 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Physician's Name | Michael Minozzi |
| Physician's Phone Number | 9199670771 |
| Preferred Medical Facility | UNC |
| Current Medications and Dosages | None |
| Will your child need the learning environment or assignments adapted in any way? | No |
| Insurance | |
| Name of Policy Holder | Brian Curry |
| Employer | self-employed |
| Insurance Company | Blue Cross Blue Shield |
| Policy Number | Y2K102836630 |
| 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 | Andrea Curry |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
