| Student's Name | Rory Bane |
|---|---|
| Date Of Birth | 12/07/2017 |
| T shirt size | Child S |
| PARENT INFORMATION | |
| Parent 1 | Michelle Bane |
| Cell Phone | (703) 577-8839 |
| Home/Work Phone | (703) 577-8839 |
| Parent 2 | Todd Bane |
| Cell Phone | (804) 519-3673 |
| Home/Work Phone | (804) 519-3673 |
| Emergency Contact 1 | Michelle Bane |
| Relationship | Mother |
| Phone Number | (703) 577-8839 |
| Emergency Contact 2 | Todd Bane |
| Relationship | Father |
| Phone Number | (804) 519-3673 |
| ALLERGY INFORMATION | |
| Does this child have any known allergies? | No |
| OTHER MEDICAL INFORMATION | |
| Current Medications and Dosages | Daily Multivitamin |
| 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 | Todd Bane |
| Employer | Trellix |
| Insurance Company | Cigna open access plus |
| Policy Number | U5448939704 |
| 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 | Michelle Bane |
| Signature |
OFFICE & ADMISSIONS: (919) 672-4954|director@deerstream.org
