CWA SPONSORED FUNCTION
|
|
- Allan Miles
- 5 years ago
- Views:
Transcription
1 CWA SPONSORED FUNCTION REGISTRATION AND PERMISSION FORM AND RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT.... REGISTRATION PLEASE PRINT AND COMPLETE EACH ITEM IN FULL Registrant s Name: (separate form for each Registrant.) Sex: Male Female Age: Birth Date: Address: City: State: Zip: Has Registrant previously attended CWA Function? Yes No Parent/Legal Guardian: Address (if different from Registrant s): Telephone: Home: ( ) - Work: ( ) - Mobile: ( ) - Other: ( ) Certain individuals are restricted or prohibited from possessing firearms, ammunition, and/or dangerous weapons because of a court order, a prior conviction, or immigration status. Can you legally possess a firearm and ammunition? [ ] Yes [ ] No... PERMISSION TO PARTICIPATE IN CAMP ACTIVITIES, AND RELEASE AND WAIVER OF LIABLITY AND INDEMNITY AGREEMENT The, sponsored by the California Waterfowl Association (CWA), is set in a natural environment. The Registrants participate in sporting clays, water activities, archery, and other outdoor or sporting activities, as described in the CWA event flyer. The Undersigned parent/guardian hereby requests that the above-named Registrant be permitted to attend the CWA Function. In consideration for the Registrant being permitted to attend the event and to participate in the activities described in the CWA event flyer, other than those activities, if any, designated in paragraph 5, below, the Undersigned, for him/herself, his/her personal representative, assigns, heirs, relatives or next of kin, the Registrant, and any other parent or guardian, acknowledges, agrees, and represents the following: 1. The Undersigned acknowledges and understands that the Registrant will be exposed to certain risks of injury presented by the natural environment in which the camp is located. 2. The Undersigned further acknowledges and understands that the Registrant risks being injured if he/she participates in such activities as sporting clays, water activities, archery, and similar outdoor and sporting activities, as described in the CWA event flyer. 3. The Undersigned expressly agrees that, in consideration for the privilege of attending this event, the Registrant shall use all services and facilities at the Registrant s sole risk. 4. The Undersigned affirms that he/she has read the CWA Function event flyer and is familiar with the activities that are offered to the Registrant while he/she is at the camp. 5. The Undersigned specifies that the Registrant may participate in any of the activities listed in the CWA event flyer and offered while he/she is attending the camp.
2 6. Although CWA does not expect any changes in the event schedule or activities, the Undersigned agrees that, due to unforeseen circumstances, changes may occur and that CWA is not obligated to give the Undersigned prior notification of such changes. 7. If any emergency medical procedures or treatment are required by the Registrant during his/her attendance at the camp or participation in camp activities and services, the Undersigned consents to the camp staff taking Registrant for emergency care and arranging for and consenting to the procedures or treatment recommended by the treating physician, pursuant to the Registrant Health Form included in the registration materials and agreed to as a condition of Registrant s attendance at the camp. The Undersigned hereby agrees to pay for the costs of any such medical procedures or treatment. 8. The Undersigned knowingly, voluntarily, and for adequate consideration releases and waives, and further agrees to indemnify, hold harmless, and reimburse CWA, members of its Board of Directors, and its employees and volunteers from and against any claim which the Registrant, the Undersigned, any other parent or guardian, relative or next of kin of the Registrant, or any other person, firm, or corporation may, now or hereafter have or claim to have, known or unknown, seen or unforeseen, directly or indirectly, or within or without the control of those released, for or on account of any losses, damages, personal injuries, pain and suffering, death, property damage, or contract claims resulting from, or arising out of, during, or in connection with the Registrant s attendance at the CWA Function and participation in the activities described in the CWA event flyer, and the rendering of emergency medical procedures or treatment, if any. 9. The Undersigned hereby agrees not to sue or file a claim against CWA, members of its Board of Directors, or its employees or volunteers for any death or injury to the Registrant or the Registrant s personal property sustained in connection with the Registrant s attendance at camp and participation in the activities described in the CWA event flyer, and the rendering of emergency medical procedures or treatment, if any. 10. The Undersigned expressly agrees that this Release and Waiver of Liability and Indemnification Agreement is attended to be as broad and inclusive as is permitted by California law and, if any portion of this Agreement is held invalid, it is further agreed that the remaining portions shall continue in full force and effect. 11. By signing this Waiver, the Undersigned acknowledges that he/she has carefully read, fully understands the contents of, and has voluntarily signed this Release and Waiver of Liability and Indemnification Agreement and further agrees that no oral representations, statements, or inducements apart from this Agreement have been made. 12. Certain individuals are restricted or prohibited from possessing firearms, ammunition, and/or dangerous weapons because of a court order, a prior conviction, or immigration status. Please mark an X in the appropriate box below and sign this form. I certify that I am a United States Citizen or lawfully within the United States, and that I am not restricted or prohibited due to court order, terms of probation, terms of parole, immigration status, or violations of certain sections of law from possessing firearms, ammunition, and/or dangerous weapons. I certify that I am restricted or prohibited due to court order, terms of probation, terms of parole, immigration status, or violations of certain sections of law from possessing firearms, ammunition, and/or dangerous weapons, and I understand that I cannot handle firearms while attending a Hunter Education class. If you are restricted or prohibited, speak with the instructor immediately. By signing below, I declare under penalty of perjury that the foregoing is true and correct. Date:, 20 Signature of Parent or Legal Guardian (Registrant is under 18 years of age) Date:, 20 Signature of Registrant
3 CWA WEEKEND WATERFOWL CAMP CAMPER HEALTH FORM To be completed by Parent or Guardian Camper s Name: Age: Sex: Male Female Camp Dates: Complete and correct health information and a parent/legal guardian s proper signature are REQUIRED before Camper will be permitted to attend camp. CAMPER S HEALTH HISTORY Check any condition the Camper has that a camp counselor should know about: Heart Condition Bed-Wetting Rheumatic Fever Diabetes Eye/Ear Infection Sleep-Walking Allergy/Bee Sting Convulsions Homesickness Drug Allergy Poison Oak Contact Lenses Headaches Nosebleeds HIV Food Allergies Other Please explain any items marked above: Is Camper taking any medication? Yes No / Name(s) of any medication: Does Camper have any physical impairment which requires accommodation? Yes No Explain: Other health information the camp counselors should know about: IMPORTANT: Please notify the camp if camper has been exposed to any communicable diseases within three weeks prior to reporting to the camp. Page 1 of 2
4 Camper Health Form (continued) IMMUNIZATION HISTORY D.P.T. Series Booster Polio Booster Measles Booster Other Booster Date of most recent Tetanus Immunization IN CASE OF EMERGENCY, I,, as the parent or legal guardian of, understand that first aid will be available at camp, that the Camper will be closely supervised, and that, if serious injury or illness develops, medical and/or hospital care will be given. I further understand that I will be notified in case of serious injury or illness. However, if it is impossible to contact me, I give my permission to the physician selected by the camp staff to hospitalize, to secure proper treatment for, and to order prescriptions, anesthesia, or surgery for my child named above. Medical Insurance: Family Physician: Subscribers Name: Phone (Office): Member or Group Number: Date:, 20 Signature of Parent/Legal Guardian Printed Name of Parent/Legal Guardian Emergency Contact Telephone Numbers: Name: Relation: Home: Work: Mobile: Other: Additional Comments: Page 2 of 2
5 CAmp CWA Weekend Waterfowl Camp Code of Conduct Camper s Name: Camp Dates: During my stay at the CWA Weekend Waterfowl Camp: I promise to conduct myself in a responsible manner, treating everyone with courtesy and respect. I will consider myself an invited guest of Rancho Esquon and conduct myself in such a way that I may be welcome to return in the future. I will obey the rules of the camp and the direction and instructions of the camp staff, and I will insist that others with me do the same. I will not participate in any verbal or physical abuse toward any other camper or adult. I will treat all animals and property with respect. I understand that if I violate any of the above I will be required to immediately call my parents to explain what happened and what I did wrong. This call will also inform my parents that the next violation will result in a call home to immediately come to pick me up and take me home. Date:, 20 Signature of Camper Date:, 20 Signature of Parent/Legal Guardian
6 CWA WEEKEND WATERFOWL CAMP PERMIT FOR CAMPER PHOTOGRAPHIC AND VIDEOTAPE REPRODUCTION Camper s Name: Camp Dates: The Undersigned parent/legal guardian of the Camper named above hereby gives permission to California Waterfowl Association (CWA) to photograph, film, or videotape the Camper during the time the Camper is attending a CWA camp and participating in any activities and services at or sponsored by the camp. 1. The Undersigned understands and acknowledges that these photographs and/or electronic reproductions may be used for promotional and/or public information purposes, including, but not limited to, CWA newsletters and web sites. The Undersigned further understands and acknowledges that the Camper s name may be included along with the photograph and/or electronic reproduction. 2. The Undersigned unconditionally releases and discharges CWA, members of its Board of Directors, and its employees and volunteers from all claims, rights, and causes of action arising out of or in connection with the use or publication of these photographs and/or electronic reproductions, including, without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefit of the assigns, licensees, and personal representatives of CWA, members of its Board of Directors, and its employees and volunteers, as well as to the parties for whom the pictures were taken. 3. The Undersigned agrees that such photographs and electronic reproductions may be used, revised, or reproduced for distribution to other nonprofit organizations that organize and/or promote children s sports activities or the news media for promotional, educational, or informational use. Date:, 20 Signature of Parent or Legal Guardian (Camper is under 18 years of age.) Printed Name of Parent or Legal Guardian
Baa Hózhó Navajo Prep Math Summer Camp 2017
Math Summer Camp 2017 Application Packet Grades 7-12 May 30-June 3, 2017 Navajo Preparatory School, Farmington, NM Residential Camp Application Checklist A complete application must include the following:
More informationJDRF Oklahoma. Youth Ambassador Program 2017 Promise Ball 20 th Anniversary. Information Packet
JDRF Oklahoma Youth Ambassador Program 2017 Promise Ball 20 th Anniversary Information Packet Dear Prospective JDRF Youth Ambassador: I am writing to invite you to participate in the 2017 JDRF Youth Ambassador
More informationSMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC PHYSICAL THERAPY PATIENT INFORMATION CITY: STATE: ZIP CODE:
PHYSICAL THERAPY PATIENT INFORMATION DATE: NAME: DATE OF BIRTH: ADDRESS: CITY: STATE: ZIP CODE: *E-MAIL: HOW DID YOU HEAR ABOUT SMITH PHYSICAL THERAPY AND RUNNING ACADEMY? EMERGENCY CONTACT: REFERRING
More informationAutism Society of Greater Orlando s 2018 Autism Walk & Family Fun Day **Annual Fundraising Event**
Autism Society of Greater Orlando s 2018 Autism Walk & Family Fun Day **Annual Fundraising Event** The Autism Society of Greater Orlando is hosting its 13 th Annual Autism Walk & Family Fun Day inside
More information2018/19 The Rock Youth Center Registration Packet. Instructions
2018/19 The Rock Youth Center Registration Packet Instructions Please review all pages of this document carefully. Your signature on pages 3,6 and 8 will verify that you have read the rules and guidelines
More informationPROGRAM YEAR 2018 REGISTRATION PACKAGE
PROGRAM YEAR 2018 REGISTRATION PACKAGE Full Stride Track Club is a competitive track club for Contra Costa and Solano County youth ages 5 to 18 years old. We are committed to providing our youth with a
More informationHello, Fundraiser! All the best, Julie Lowe Ronald McDonald House Charities of Greater Washington, DC
Hello, Fundraiser! We are so excited to work with you on your fundraising event in support of Ronald McDonald House Charities of Greater Washington, DC and help Raise Love for the families we support!
More informationWaiver, Release and Hold Harmless Agreement Personal Training Services
Waiver, Release and Hold Harmless Agreement Personal Training Services I,, the undersigned, affirm that I am participating voluntarily in Personal Training Services. (Print name) I (together with my parent
More informationPresbyterian Night Shelter Volunteer Application
Presbyterian Night Shelter Volunteer Application Thank you for your interest in the Presbyterian Night Shelter (PNS). Please complete this application as well as the attached documents and return to: Presbyterian
More informationENROLMENT FORM. Title: First Name: Surname: Postal Address: Postcode: Emergency Contact: Relationship: Phone: What is your main fitness goal?
ENROLMENT FORM Personal Information Title: First Name: Surname: Date of Birth: Sex: Female Male Postal Address: Postcode: Phone: Home: Work: Mobile: Email: Preferred method of contact: Letter Phone Email
More informationWings to Soar Camp CHILD/TEEN REGISTRATION
Wings to Soar Camp CHILD/TEEN REGISTRATION *** Pre-registration for Wings to Soar Camp is necessary*** For each child who will be attending, please send this completed registration form with medical information
More informationUCSB Olympic Weightlifting Platform Area Specific Policies, Safety, and Liability Protocol
Patron Name: r Staff / Faculty r Community Member r Student Exp. Grad year UCSB Olympic Weightlifting Platform Area Specific Policies, Safety, and Liability Protocol Patron please initial each item: 1.
More informationThe Society of St. Vincent de Paul. Riverwalk. San Marcos, TX
The Society of St. Vincent de Paul Riverwalk San Marcos, TX Saturday October 1, 2016 The Society of St. Vincent de Paul 624 East Hopkins Street San Marcos, Texas 78666 512-353-7394 River Walk for the Poor
More informationPlease everything to the address below: ITEMS TO MAIL. 1. Copy of the athletes immunization record
In order to participate in the Syracuse Indoor Showcase each player will need to EMAIL all the items below upon completion of their online registration. Your registration/spot in the showcase is not complete
More information2019 Jr. Adventure Camp and Jr. Mustangs Camp Registration Form
2019 Jr. Adventure Camp and Jr. Mustangs Camp Registration Form Camper s Name M / F Date of Birth Parent s Email Address Street Address City State Zip Parent/Guardian Home Phone Cell Phone Address (if
More informationPersonal Training New Client Packet Personal Training/Fit for Hire
Personal Training New Client Packet Personal Training/Fit for Hire Date / / Name Address City State Zip Phone Number Email Trainer Preference Male Female No Preference **If you would like to work with
More informationREQUIREMENTS: PROGRAM INCLUDES: IMPORTANT DATES: CHALLENGE WINNERS: HOW DO I PARTICIPATE IN AUBURN STRONG?
REQUIREMENTS: Auburn University student, faculty or staff Physician clearance/par Q Completed registration form 3 day food log prior to nutritional assessment Nutritional Assessment Attend @ least 2 semi-private
More informationJumpstart, Fitness Assessment, & Body Composition
Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training
More informationEXTERNAL TRAINER AGREEMENT. THIS AGREEMENT dated as of the day of, 20. BETWEEN: (the External Trainer ) - and -
EXTERNAL TRAINER AGREEMENT THIS AGREEMENT dated as of the day of, 20. BETWEEN: (the External Trainer ) - and - 2566588 Ontario Ltd. operating as Fortis Fitness West (2566588 Ontario Ltd. operating as Fortis
More informationEXTERNAL TRAINER AGREEMENT. THIS AGREEMENT dated as of the day of, 20. BETWEEN: (the External Trainer ) - and -
EXTERNAL TRAINER AGREEMENT THIS AGREEMENT dated as of the day of, 20. BETWEEN: (the External Trainer ) - and - Fortis Fitness Inc. (Fortis Fitness Inc. or Fortis Fitness or the Companies ) This Agreement
More information*Your address will be added to our WODIFY system. You may receive correspondence from both WODIFT and Crossfit Toowoomba from time to time.
Name: Date of Birth: Emergency Name and Contact No: Address: Contact Number: Email Address Occupation: Have you done Crossfit Before? Gender: If so where? *Your email address will be added to our WODIFY
More informationSober Living Fox Cities Participant Contract Revised
Sober Living Fox Cities Participant Contract Revised 3.14.2016 This is a legal and binding document, please read it very carefully and initial the blank lines doing so indicates that you have read and
More informationDIOCESE OF HARRISBURG DIOCESAN CATHOLIC COMMITTEE ON SCOUTING
June 2018 DCCS Retreat 2018 150 th Diocesan Anniversary! Dear Scouts, Venturers and Scouters, Join us for the 40 th Annual Diocesan Catholic Scout Retreat is the weekend of September 14, 15 & 16, 2018
More informationWV Address WV Phone # Father / Male Guardian Information (required) Work Phone # Home Phone # Cell Phone # Home Address (if different)
2016 Freestyle/Freeski BagJump/Trampoline Skills Training Sessions & 6 Day Camp Application For each athlete, please complete, sign and return all pages of this application and include payment in full
More informationPlease complete the medical history section below so that we can be sure to respond to any
200hr Yoga Teacher Training Application Please fill out this form and email it to teachertraining@ahamyoga.com with Teacher training application 2016 as the subject line. Any enrollments without this form
More informationPersonal Training Health Screening Questionnaire
RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:
More informationJuly 5th-7th, 2016 Thompson Rivers University, Kamloops
Speak Out Loud Conference July 5th-7th, 2016 Thompson Rivers University, Kamloops Who? Members 13 to 19 years old before January 1st When? July 5th-7th 2016 Where? Thompson Rivers University, Kamloops
More informationTEACHER TRAINING APPLICATION
Introduction TEACHER TRAINING APPLICATION Thank you for your interest in the Hot 8 Yoga Teacher Training Program! Below you will find detailed instructions on how to apply. Please be aware that the Hot
More informationFirst-Ever Youth Playhouse Build!
Attention all Bryan and College Station youth between the ages of 7 and 15! Bryan/College Station Habitat for Humanity needs you! Our first-ever Youth Playhouse Build is a two-day event designed to engage
More informationJDRF Hampton Roads Youth Ambassador Program Description
JDRF Hampton Roads Youth Ambassador Program Description The Youth Ambassador Program offers youth opportunities for personal growth and development of leadership skills, while creating awareness for JDRF
More informationA Tradition of Excellence
A Tradition of Excellence November 7 2017 Via Electronic Mail Donald P O Neil RE: 17-77 Response to FOIA Request Thank you for writing to Hinsdale Township High School District 86 with your request for
More informationApplication to Livingston Robotics Club Season Part A: Student information. Name: (Student) Home Address:
Due s: July 30, 2017 for FLL and FTC Mail to: P.O. Box 771, Livingston, NJ 07039 Email to info@livingstonrobotics.org Application to Livingston Robotics Club Part A: Student information Name: (Student)
More informationGIRL FORM. Address City State Zip ( ) ( ) HEALTH INSURANCE INFORMATION Name of Insurance Company Address Insurance Company Phone Number
: : GIRL FORM Girl Scouts, Hornets Nest Council 2018 Summer Camp Health/Permission Form Please Note: NO girl will be allowed to attend any camp without a completed and signed Summer Camp Health/Permission
More information2013 U.S. OPEN TAEKWONDO CHAMPIONSHIPS VOLUNTEER GUIDE AND APPLICATION
2013 U.S. OPEN TAEKWONDO CHAMPIONSHIPS VOLUNTEER GUIDE AND APPLICATION USA Taekwondo 1 Olympic Plaza Colorado Springs, Colorado 80909 Phone : (719) 866-4632 Fax : (719) 866-4642 www.usa-taekwondo.us OFFICIAL
More informationWhite Plains YMCA 2016 Summer Camp Registration Form
White Plains YMCA 2016 Summer Camp Registration Form Camper Information Child s First Name: Child s Last Name: Date of Birth: Gender: Age: S L XL What grade will your child be entering in the Fall of 2016?:
More informationCity of Carson 701 E. Carson St., Carson, CA Telephone: (310) ; ci.carson.ca.us
OFFICE USE ONLY Case No. City of Carson 701 E. Carson St., Carson, CA 90745 Telephone: (310) 830-7600; ci.carson.ca.us Application Submittal Date Fee Accepted By SUPPLEMENTAL APPLICATION FOR COMMERCIAL
More informationDIOCESE OF CORPUS CHRISTI
Office of Youth Ministry DIOCESE OF CORPUS CHRISTI PO Box 2620 Corpus Christi, Texas 78403 (361) 882-6191 Fax (361) 693-6787 www.diocesecc.org/youth YouthOffice@diocesecc.org DIOCESAN CONFIRMATION RETREATS
More informationWelcome to the CANYON WELLNESS PROGRAM!
Welcome to the CANYON WELLNESS PROGRAM! This program is designed to allow you to continue/initiate the pursuit of your health/wellness goals. You may have just completed a course of Physical Therapy or
More information,
, o o o : : Girl Scouts, Hornets Nest Council 2018 Summer Camp Health/Permission Form SECTION ONE (must be completed every year for ALL campers) CAMPER INFORMATION Camp Session Name and Date: Camper Name
More informationAfter School Café: Fall 2017 TUTOR APPLICATION DEADLINE: September 1, 2017
Office Use Only TUTOR APPLICANT SECTION Address: 1990 Market St. Concord, CA 94520 After School Café: Fall 2017 TUTOR APPLICATION DEADLINE: September 1, 2017 Date Completed: Received By: Name Last First
More informationVillage of Orland Park Recreation Department. Adopt-A-Park and Path. Handbook
Village of Orland Park Recreation Department Adopt-A-Park and Path Handbook Table of Contents Overview........1 Guidelines......2 Safety Guidelines......3 Available Parks/ Bike Trails......4 Attached Documents
More informationGARDEN STATE SLEEP CENTER REGISTRATION FORM PATIENT INFORMATION:
GARDEN STATE SLEEP CENTER REGISTRATION FORM (Please Print) Today s Date: Primary Care Physician: PATIENT INFORMATION: Last Name: First: Middle: Mr. Miss Dr. Mrs. Ms. Marital Status (Please check one) Single
More informationThe Children s Addiction Prevention Program at Brighton Center for Recovery
The Children s Addiction Prevention Program at Brighton Center for Recovery Dear Parents: Thank you for your interest in the Children s Program at Brighton Center for Recovery and for giving your child
More information2017 Candidate Application Applicant Complete the form below. Please bring a copy to your scheduled interview.
2017 Candidate Application Applicant Complete the form below. Please bring a copy to your scheduled interview. Last Name First Middle Initial Nickname Current Age Current Grade Female Male Address City
More informationOxford Parks & Recreation Department. Fit After 50 Workout Center. Membership Packet
Oxford Parks & Recreation Department Fit After 50 Workout Center Membership Packet The Fit After 50 (FA50) Workout Center Regulations have been established to make it possible for you to use the facility
More informationSacrament of Confirmation Registration Form Year 2 St. Cornelius Catholic Church
Sacrament of Confirmation Registration Form Year 2 St. Cornelius Catholic Church 2017-2018 (Please type or print clearly) Name of Candidate: Age: Address: Street City Zip Home Phone: ( ) Cell or other:
More informationTROY YOUTH FOOTBALL ASSOCIATION TROYCOWBOYS 2018 REGISTRATION FORM
TROYCOWBOYS 2018 REGISTRATION FORM Registration Fees Flag : $160 Freshman - JV: $180 Varsity : $150 Participant Information Name: Address: Date of Birth: City: Zip Code: Mother s Cell Number: Parent/Guardian
More informationHAKU BALDWIN CENTER Where special people and animals come together.
HAKU BALDWIN CENTER Where special people and animals come together. Our vision is to foster therapeutic partnerships between people and animals which we believe promotes the growth and development of healing
More informationAPPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY)
1317 w. Washington Blvd. Fort Wayne, In. 46802 260-424-2341 APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY) NAME: _ FIRST MI LAST DATE OF BIRTH: / / AGE: SOCIAL SECURITY NUMBER: LAST OR CURRENT ADDRESS:
More informationDear Parent/Guardian:
Dear Parent/Guardian: The of Delta Sigma Theta Sorority, Incorporated, invites you and your teenager to join our 2016-2017 E.M.B.O.D.I (Empowering Males to Build Opportunities for Developing Independence)
More informationCRITICAL POLICY REFERENCE MANUAL FILE CODE: X Monitored X Mandated Sample Policy X Other Reasons
CRITICAL POLICY REFERENCE MANUAL FILE CODE: 5141.21 X Monitored X Mandated Sample Policy X Other Reasons ADMINISTERING MEDICATION The board shall not be responsible for the diagnosis and treatment of student
More informationHome Sleep Test (HST) Instructions
Home Sleep Test (HST) Instructions 1. Your physician has ordered an unattended home sleep test (HST) to diagnose or rule out sleep apnea. This test cannot diagnose any other sleep disorders. 2. This device
More informationTown of West Seneca Youth Engaged in Service New Volunteer Orientation Guide
Town of West Seneca Youth Engaged in Service New Volunteer Orientation Guide Important Information: Youth & Recreation Department Office Phone Number: 674-6086 Program Email: wsyes@twsny.org Program Information
More informationShould you have questions or concerns, please contact the Program Supervisor at the location your child is registered.
Community Services Department, Recreation Division 201 City Centre Drive MISSISSAUGA ON L5B 2T4 mississauga.ca/recreation Dear Parent/Guardian, We are excited to have you join us for camps this season!
More informationRhode Island Board of Examiners in Dentistry Room Capitol Hill Providence, RI Instructions and License Application for:
CHECK LIST Application License Verification Employment letter Con. Ed. Compliance Tax Addendum **FOR OFFICE USE ONLY** Receipt # ID # Issue Date License # Rhode Island Board of Examiners in Dentistry Room
More informationUniversity of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS
Name (Last, First, MI) University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS of Birth Address Sex M / F Sport Phone City State Zip
More informationASTHMA OR ANAPHYLAXIS MEDICAL MANAGEMENT PLAN I. CONTACT AND PLAN INFORMATION
Plan For (Student) Dated: ASTHMA OR ANAPHYLAXIS MEDICAL MANAGEMENT PLAN I. CONTACT AND PLAN INFORMATION Student s Name: Date of Birth: / / (Month) (Day) (Year) Health Condition: Asthma Anaphylaxis (For
More informationMEMBER SHARE A Pastoral Medical Association - Private Membership Program MEMBER SHARE AGREEMENT (MSA)
MSA P MEMBER SHARE A Pastoral Medical Association - Private Membership Program MEMBER SHARE AGREEMENT (MSA) I, the undersigned applicant for the value, benefits and mutual promises herein, do hereby apply
More informationInitial Clinical History and Physical Form
601 E FM 544, Suite 400, Murphy, TX, 75094 TEL: 972-442-4700 Initial Clinical History and Physical Form Patient Information Name: Age: of Birth: / / Sex: Male / Female Marital Status: Single Married Divorced
More informationEmployment Application
Please Print Date: Name: Business Telephone ( ) Cell Phone ( ) Home Telephone ( ) Email Present Address Permanent Address, if different from present address: Employment Desired Position applying for: Job
More informationMEMBERSHIP APPLICATION
MEMBERSHIP APPLICATION Join Date: Full Pay Draft 20/20 Membership Type: Household One Parent Household Two Adult Household Senior Household Adult Young Adult Youth Senior First Name MI Last Birth Date
More information2014 YouthWorks Participant Release Form Youth & Youth/Beyond Trips Bring original and two copies on your trip
Name of Participant (please print): Grade as of Fall 2013 (if student): s Attending: Name of Site: Church Name: Trip Leader: Liability Release Agreement I/we understand that there are inherent risks involved
More informationAdministering Medicines to Students Asthma Inhaler Exemption
Administering Medicines to Students Asthma Inhaler Exemption Any school employee authorized in writing by the district administrator or school principal: 1. May assist in the self-administration of any
More informationPeer Pal Information (ages 13-16)
Peer Pal Information (ages 13-16) Community Coaching Program Include Autism s Community Coaching program is a small group, community behavioral and social skill development & ABA therapy program for school
More informationBack Bay Therapeutic Riding Club Inc Cypress Ave. Newport Beach, CA
Back Bay Therapeutic Riding Club Inc. 20262 Cypress Ave. Newport Beach, CA 92660 949-474-7329 BACK BAY THERAPEUTIC RIDING CLUB RIDER REGISTRATION/HEALTH HISTORY/RIDER PROFILE (UPDATED ANNUALLY) Name of
More informationAPPLICATION INSTRUCTIONS
APPLICATION INSTRUCTIONS TEACHER TRAINING PROGRAMS Application Deadlines To process your application, please send your complete application no later than one week prior to the program start date. However,
More informationPatient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
More informationDIOCESE OF CORPUS CHRISTI
Office of Youth Ministry DIOCESE OF CORPUS CHRISTI 620 Lipan St. Corpus Christi, Texas 78401 (361) 882-6191 Fax (361) 693-6787 www.diocesecc.org/youth YouthOffice@diocesecc.org DIOCESAN CONFIRMATION RETREATS
More informationCivilian Wellness and Civilian Fitness Program (AR Health Promotion)
Civilian Wellness and Civilian Fitness Program (AR 600-63 Health Promotion) Enrollment Packet Wellness Program Coordinators: Wendy LaRoche (wendy.laroche@us.army.mil) Celestine Beckett (celestine.beckett.civ@mail.mil)
More informationOKLAHOMA SCHOOL FOR THE DEAF DEAF AND HARD OF HEARING SUMMER CAMP HIGH SCHOOL JUNE 10-15, 2018 ELEMENTARY SCHOOL JUNE 10-13, 2018 REGISTRATION DAY
OKLAHOMA SCHOOL FOR THE DEAF DEAF AND HARD OF HEARING SUMMER CAMP HIGH SCHOOL JUNE 10-15, 2018 ELEMENTARY SCHOOL JUNE 10-13, 2018 REGISTRATION DAY WHEN: JUNE 10 th (High School) JUNE 10 th (Elementary)
More informationPersonal Training Registration Packet
Personal Training Registration Packet Client Name: Date: Program Information and Policies Welcome to the UCSB Personal Training Program! We are delighted that you chose us as a part of your commitment
More information7. Pledge form B, for use if the Parish SVDP chooses to raise funds at the Parish Level by general Sponsorship (attachment 5)
Contents: 1. The Walker Registration Form (attachment 1) 2. The SVDP Liability Waiver (attachment 2) 3. The SVDP Photo Release Form (attachment 3) Save time the morning of the walk! Parish walkers can
More informationThe forms in this packet are to be completed and submitted at check-in for ALA Palmetto Girls State on Sunday, June 10, 2018.
The forms in this packet are to be completed and submitted at check-in for ALA Palmetto Girls State on Sunday, June 10, 2018. These forms are NOT to be sent-in prior to arrival at ALA Palmetto Girls State
More informationMaster Artist Workshop Series
Master Artist Workshop Series Friday - Saturday October 23-24, 2015 Yavapai-Apache Cultural Resource Center Supported by the Margaret A. Cargill Foundation, the Heard Museum Master Artist Workshop series
More informationWe are inviting you to participate in a research study/project that has two components.
Dear TEACCH Client: One of the missions of the TEACCH Autism Program is to support research on the treatment and cause of autism and related disorders. Therefore, we are enclosing information on research
More informationCommunity Education. City State Zip Code. Term (please circle one) Summer 20 Fall 20 Winter 20 Spring 20
Student ID # 1651 Lexington Ave, Astoria, OR 97103 Community Education Today s Date: Bandit Community Fitness Bandit Community Fitness offers access to the College s weight room, cardio room and running
More information2016 Program Application
George Biddle Kelley Education Foundation, Inc. Alpha Esquires 2016 Program Application Alpha Esquire (ESQ) Mentorship Program Description & Overview: The Alpha ESQ mentorship program is designed to provide
More informationDELTA DENTAL PREMIER
DELTA DENTAL PREMIER PARTICIPATING DENTIST AGREEMENT THIS AGREEMENT made and entered into this day of, 20 by and between Colorado Dental Service, Inc. d/b/a Delta Dental of Colorado, as first party, hereinafter
More informationJanuary To: 4-H Members From: 4-H Counselor Committee, Camp Crowder 4-H Camp Dale Hunsburger, Shaun Murphy, Janet Sager and Rick Smith
Clinton County P.O. Box 294 101 South Main Plattsburg, MO 64477 PHONE (816) 539-3765 FAX (816) 539-3766 E-MAIL clintonco@missouri.edu WEB SITE http://extension.missouri.edu January 2013 To: 4-H Members
More informationSTRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING
STRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING Please take the time to read through all the information and ensure all relevant forms are completed. The following questionnaire and waivers
More informationCAMP SOCIAL 2018 ENROLLMENT APPLICATION FOR CAPE GIRARDEAU
ENROLLMENT APPLICATION FOR CAPE GIRARDEAU Name of Camper: Date of Birth: County: * A separate Enrollment Application and Camper Portfolio must be completed for each child. Parent/Guardian Information Name
More informationCity State Zip. Home Phone Mobile Phone. Can we text you appointment reminders? Yes / No If yes, who is your wireless carrier?
CryoBoost Lubbock 5206 82 nd St., Suite 15 (inside Austin Chiropractic) CryoBoost Allen 801 S Greenville Ave., Suite 115 (inside Wellness) Physical Readiness Questionnaire Name Date Address City State
More informationCONDITIONS OF SERVICES RENDERED
CONDITIONS OF SERVICES RENDERED FINANCIAL AGREEMENT: I agree, whether I sign as agent or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate
More informationRecovery and Wellness through Cryotherapy Egan Drive* Suite 191* Savage, MN 55378* *cryostrong.com. Physical Readiness Questionnaire
CRYOSTRONG WHOLE BODY CRYOTHERAPY Recovery and Wellness through Cryotherapy 6001 Egan Drive* Suite 191* Savage, MN 55378*952-220-2997*cryostrong.com Physical Readiness Questionnaire Date: Customer Name:
More informationTalisman Therapeutic Riding, Inc. PO Box 300, Grasonville, MD
Volunteer Application (Page 1 of 6) General Information Form - Please Print Clearly and Complete Fully (Last Name) (First Name) (Middle Initial) (Nickname) Street Address: City: State: Zip Code: Home Phone:
More informationNEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
More informationPART 2: CAMPER APPLICATION PACKET
Monday June 19 Friday June 23, 2017 PART 2: CAMPER APPLICATION PACKET APPLICATION DEADLINE: May 15, 2017 (Print, Complete, Sign & Return by mail, fax, email or drop off) Epilepsy Foundation Central & South
More informationWellness Department. Non-Resident Pool Membership Packet. Page 1
Wellness Department Non-Resident Pool Membership Packet Page 1 Dear Non-Resident, Thank you for your inquiry into the Aquatic programs at Brethren Village. We offer the opportunity for residents in the
More informationMOUNT VERNON CITY SCHOOL DISTRICT ATHLETICS and HEALTH SERVICES
STUDENT NAME SPORT DATE GRADE LEVEL COACH PARENT/GUARDIAN ATHLETIC PARTICIPATION CONSENT FORM *PLEASE RETURN THIS FORM ON THE DAY THE ATHLETE HAS HIS/HER PHYSICAL/CONFERENCE* Dear Parent or Guardian: Your
More information2018 Coos Bay Summer Seminar July 19-22, 2018
2018 Coos Bay Summer Seminar July 19-22, 2018 Greetings, July is fast approaching and now is the time to begin planning to attend the 2018 Western Pacific Tang Soo Do Association Summer Seminar. 2018 marks
More information** EARLY BIRD ** REGISTRATION FEE:
** EARLY BIRD ** REGISTRATION FEE: Turn in your registration form and waiver form, along with payment, by Friday, May 4 and save $15.00 on each $75.00 camp! After May 18, registration will only be accepted
More informationFUTURE SCIENCE LEADERS COUNSELORS-IN-TRAINING PLUS PROGRAM OVERVIEW AND APPLICATION
FUTURE SCIENCE LEADERS COUNSELORS-IN-TRAINING PLUS PROGRAM OVERVIEW AND APPLICATION Future Science Leaders (FSL) Counselors-in-Training (CIT)+ is a summer program for students entering 7 th -9 th grade
More informationBILL TO: Comprehensive Health Services, Inc Parkridge Blvd, Suite 200 Reston, VA (703) or (800)
DHS FITNESS TESTING INSTRUCTIONS NOTE: Failure to comply with these instructions will result in a delay of the candidate s application process and may ultimately deter payment to your facility. 1.) 2.)
More informationUSE OF ALCOHOLIC BEVERAGES ON CAMPUS GUIDELINES
Forsyth Conference Center at Lanier Technical College Forsyth Campus 3410 Ronald Reagan Blvd Cumming, GA 30041 678-341-6633 Fax: 678-989-3113 forsythconferencecenter/laniertech.edu USE OF ALCOHOLIC BEVERAGES
More informationTomorrow s SMILES Program
Do you know a promising teen whose future is at-risk due to lack of dental treatment? Would your teen and his or her family understand, appreciate, and value pro-bono dental care? If so, your teen may
More informationFRIDAY, SEPTEMBER 15 REGISTER YOUR TEAM NOW AND BEGIN FUNDRAISING TO SUPPORT UNITED WAY AND WIN PRIZES!
FRIDAY, SEPTEMBER 15 REGISTER YOUR TEAM NOW AND BEGIN FUNDRAISING TO SUPPORT UNITED WAY AND WIN PRIZES! TEAM CAPTAIN REGISTRATION FORM IMPORTANT: Please note that your $300 team registration fee must be
More informationMaster Artist Workshop Series
Master Artist Workshop Series Thursday - Saturday September 17-19, 2015 Inn of the Mountain Gods, Mescalero, NM Supported by the Margaret A. Cargill Foundation, the Heard Museum Master Artist Workshop
More informationADMINISTRATION OF MEDICATIONS AT THE WALDORF SCHOOL OF PRINCETON
ADMINISTRATION OF MEDICATIONS AT THE WALDORF SCHOOL OF PRINCETON MEDICATION DURING SCHOOL HOURS Whenever possible, the parent/guardian should arrange with their physician for medication to be given outside
More informationPREJUDICE AWARENESS SUMMIT COMMUNITY FACILITATOR APPLICATION
Please return the application pages to our office via email, fax, or mail by September 22. Information for Applicants Keep this Page! What is the Prejudice Awareness Summit (PAS)? The Prejudice Awareness
More information