OKEECHOBEE COUNTY CIVIC CENTER SUMMER PLAY CAMP REGISTRATION FORM
|
|
|
- Santiago Ortíz Gómez
- hace 5 años
- Vistas:
Transcripción
1 OKEECHOBEE COUNTY CIVIC CENTER SUMMER PLAY CAMP REGISTRATION FORM Please review "2018 Summer Play Camp General Information" prior to completing this application. All terms and provisions including, but not limited to, those described therein and in this registration form shall govern your child's enrollment and participation. Should you still have questions or concerns after reviewing the information provided, please discuss them with Parks and Recreation staff before submitting this registration form. We will be having SPC2018 meet and greet camp orientation for parents on Thursday June 7th, 2018 at the Okeechobee Civic Center from 6pm-7pm. This applicant is/was a participant in the following Okeechobee County School Lunch Program: Check one: Free Reduced Fee Full Pay Sibling APPLICANT INFORMATION Last First M.I. Date of Birth Street Address Apartment/Unit # City State ZIP Siblings Shirt Size: Youth/Adult Sm. Med. Lar. XLar. XXLar. Preferred PARENT(S) OR GUARDIAN INFORMATION First & Last Street Address City First & Last Street Address City State Zip State Zip Driver License # Driver License # Home/Work # Cell # Home/Work # PLEASE INDICATE ALL SESSIONS YOUR CHILD WILL BE ATTENDING (X) Camp will be closed Wednesday, July 4 th, in observance of Independence Day. Dates June June June July July July July Attending Ext. Care *ONLY CUSTODIAL GUARDIAN CAN ALTER FORM Cell #
2 CONTACT INFORMATION Contact Person in case of emergency Relationship PHYSICAIN OR HEALTH CARE PROVIDER (REQUIRED) Allergies: YES NO List: Physical Restrictions: YES NO List: PERSONS AUTHORIZED TO SIGN THIS CHILD OUT REQUEST A SEPARATE FORM FOR ADDITIONAL NAMES IF NECESSARY. PLEASE NOTE THAT PERSONS FOR WHOM WE HAVE NO WRITTEN AUTHORIZATION WILL NOT BE ALLOWED TO SIGN OUT OR REMOVE YOUR CHILD FROM CAMP UNDER ANY CIRCUMSTANCES. ADDITIONS BY PHONE ARE NOT ALLOWED. WAVIER In consideration for Okeechobee County Parks & Recreation Department's provision of facilities, equipment, instruction and supervision for this program, the undersigned parent/guardian of the herein named applicant does hereby: 1. Assume all risks of and responsibility for possible damage or injury involved through participation in this program and understand the need to personally furnish insurance in case of injury. 2. Certify that the applicant named herein is in good health and capable of participation in this program. 3. Grant Okeechobee County permission to use, copy, exhibit, publish, or distribute my child's likeness in a photograph in and any all media now known or hereafter known, including web site entries, without payment or any other consideration in perpetuity. I understand and agree that these materials will become the property of Okeechobee County and will not be returned. 4. Agree to indemnify and hold harmless Okeechobee County departments or agents from liability resulting from applicant's participation in this program. Signature Date PERMISSION SLIP I, give my permission for Printed name of Parent or Guardian Printed name of Child to participate in the ALL off-site activities associated with the summer program. Signature Date 2018 Summer Play Camps are conducted by Okeechobee County Parks & Recreation, 1718 NW 9th Ave., Okeechobee, FL 34972, (863)
3 CONDADO DE OKEECHOBEE CENTRO CÍVICO CAMPAMENTO DE VERANO JUEGO FORMULARIO DE INSCRIPCIÓN Por favor revise "2018 juego verano Campamento General información" antes de completar esta solicitud. Todos los términos y disposiciones incluyendo, sin limitarse a, las que se describen en esto y en este formulario de inscripción se regulan por la inscripción y participación de su hijo. Si todavía tiene preguntas o dudas después de revisar la información proporcionada, por favor, discutirlas con el personal de parques y recreación antes de enviar este formulario de registro. Que el SPC2018 conocer y saludar a campo orientación para padres en jueves, 07 de junio de 2018 en el centro cívico de Okeechobee de 18:00-19:00 Este solicitante es/era a un participante en el siguiente Okeechobee County programa de almuerzo escolar: Marque uno: libre de costo reducido completo hermano pagar INFORMACIÓN SOLICITANTE Apellido Primero M.I. Dirección de la calle Apartamento/unidad # Ciudad Estado ZIP Hermanos Camiseta tamaño: Jóvenes/adultos jóvenes/adultos Sm. Med. Lar. XLar. XXLar. PADRE (S) O TUTOR INFORMACIÓN y apellido nombre Dirección de la calle Ciudad preferido y apellido nombre Dirección de la calle Ciudad Estado Zip Estado Zip # Licencia de conducir # Hogar/trabajo # De células # Licencia de conducir # Hogar/trabajo POR FAVOR INDICAR TODAS LAS SESIONES DE SU HIJO ASISTIRÁ A (X) # De células Campo se cerrará el miércoles, 4 de Julio, en observancia del día de la independencia. Cuidado Fechas de Que asisten a ext. Junio al 22 de junio 25 al 29 de junio Julio Julio al 20 de julio Julio * SÓLO CUSTODIA GUARDIAN PUEDE ALTERAR LA FORMA Fecha de nacimiento
4 INFORMACIÓN DE CONTACTO PROVEEDOR PHYSICAIN O CUIDADO DE LA SALUD (REQUERIDO) Alergias: sí NO Lista: Restricciones físicas: sí NO Lista: PERSONAS AUTORIZADAS PARA FIRMAR ESTE NIÑO SOLICITAR UN FORMULARIO POR SEPARADO NOMBRES ADICIONALES SI ES NECESARIO. Tenga en cuenta que las personas que no tenemos autorización por escrito no podrán salir o sacar al niño de campamento bajo ninguna circunstancia. NO SE PERMITEN ADICIONES POR TELÉFONO. En la consideración de Okeechobee County Departamento de parques y recreación de prestación de servicios, equipo, instrucción y supervisión de este programa, los abajo firmantes padres del solicitante en el presente documento llamado hace por este medio: Y 1. Asumir todos los riesgos y responsabilidad por posibles daños o lesiones implicadas mediante la participación en este programa y entender la necesidad de proporcionar personalmente seguro en caso de lesiones. 2. Certifica que el solicitante nombrado en este documento está en buena salud y capaz de participar en este programa. 3. Beca Okeechobee County permiso para usar, copiar, exhibir, publicar o distribuir semejanza de mi hijo en una fotografía en y todos los medios de comunicación ahora conocido o en adelante conocido, incluidas las entradas de sitio web, sin el pago o cualquier otra consideración en perpetuidad. Entiendo y acepto que estos materiales pasarán a ser propiedad del Condado de Okeechobee y no serán devueltos. 4. de acuerdo en indemnizar y mantener inofensivo Okeechobee Condado departamentos o agentes de responsabilidad resultante de la participación del solicitante en el programa. Firma Fecha HOJA DE PERMISO Yo, doy mi permiso para impreso del padre o tutor impreso nombre de niño Participar en las actividades fuera del todo asociadas con el programa de verano. Firma Fecha 2018 jugar campamentos se llevan a cabo por Okeechobee Condado de parques y recreación, 1718 NW 9th Ave., Okeechobee, FL 34972, (863)
5 OKEECHOBEE COUNTY CIVIC CENTER SUMMER PLAY CAMP REGISTRATION FORM Please review "2018 Summer Play Camp General Information" prior to completing this application. All terms and provisions including, but not limited to, those described therein and in this registration form shall govern your child's enrollment and participation. Should you still have questions or concerns after reviewing the information provided, please discuss them with Parks and Recreation staff before submitting this registration form. All CIT S will meet with Program Specialist/Camp Director starting their first week of camp to discuss rules. COUNSELOR IN TRAINING APPLICANT INFORMATION Last First M.I. Date of Birth Street Address Apartment/Unit # City State ZIP Siblings Shirt Size: Youth/Adult Sm. Med. Lar. XLar. XXLar. Preferred PARENT(S) OR GUARDIAN INFORMATION First & Last Street Address City First & Last Street Address City State Zip State Zip Driver License # Driver License # Home/Work # Cell # Home/Work # PLEASE INDICATE ALL SESSIONS YOUR CHILD WILL BE ATTENDING (X) Camp will be closed Wednesday, July 4 th, in observance of Independence Day. Dates June June June July July July July Attending Ext. Care *ONLY CUSTODIAL GUARDIAN CAN ALTER FORM Cell #
6 CONTACT INFORMATION Contact Person in case of emergency Relationship PHYSICAIN OR HEALTH CARE PROVIDER (REQUIRED) Allergies: YES NO List: Physical Restrictions: YES NO List: PERSONS AUTHORIZED TO SIGN THIS CHILD OUT REQUEST A SEPARATE FORM FOR ADDITIONAL NAMES IF NECESSARY. PLEASE NOTE THAT PERSONS FOR WHOM WE HAVE NO WRITTEN AUTHORIZATION WILL NOT BE ALLOWED TO SIGN OUT OR REMOVE YOUR CHILD FROM CAMP UNDER ANY CIRCUMSTANCES. ADDITIONS BY PHONE ARE NOT ALLOWED. WAVIER In consideration for Okeechobee County Parks & Recreation Department's provision of facilities, equipment, instruction and supervision for this program, the undersigned parent/guardian of the herein named applicant does hereby: 1. Assume all risks of and responsibility for possible damage or injury involved through participation in this program and understand the need to personally furnish insurance in case of injury. 2. Certify that the applicant named herein is in good health and capable of participation in this program. 3. Grant Okeechobee County permission to use, copy, exhibit, publish, or distribute my child's likeness in a photograph in and any all media now known or hereafter known, including web site entries, without payment or any other consideration in perpetuity. I understand and agree that these materials will become the property of Okeechobee County and will not be returned. 4. Agree to indemnify and hold harmless Okeechobee County departments or agents from liability resulting from applicant's participation in this program. Signature Date PERMISSION SLIP I, give my permission for Printed name of Parent or Guardian Printed name of Child to participate in the ALL off-site activities associated with the summer program. Signature Date 2018 Summer Play Camps are conducted by Okeechobee County Parks & Recreation, 1718 NW 9th Ave., Okeechobee, FL 34972, (863)
7 CONDADO DE OKEECHOBEE CENTRO CÍVICO CAMPAMENTO DE VERANO JUEGO FORMULARIO DE INSCRIPCIÓN Por favor revise "2018 juego verano Campamento General información" antes de completar esta solicitud. Todos los términos y disposiciones incluyendo, sin limitarse a, las que se describen en esto y en este formulario de inscripción se regulan por la inscripción y participación de su hijo. Si todavía tiene preguntas o dudas después de revisar la información proporcionada, por favor, discutirlas con el personal de parques y recreación antes de enviar este formulario de registro. Los CIT se reunirán con campo de especialista Director del programa a partir de su primera semana de campamento para discutir las reglas. INFORMACIÓN SOLICITANTE CONSEJERO EN LA FORMACIÓN Apellido Primero M.I. Dirección de la calle Apartamento/unidad # Ciudad Estado ZIP Hermanos Camiseta tamaño: Jóvenes/adultos jóvenes/adultos Sm. Med. Lar. XLar. XXLar. PADRE (S) O TUTOR INFORMACIÓN y apellido nombre Dirección de la calle Ciudad preferido y apellido nombre Dirección de la calle Ciudad Estado Zip Estado Zip # Licencia de conducir # Hogar/trabajo # De células # Licencia de conducir # Hogar/trabajo POR FAVOR INDICAR TODAS LAS SESIONES DE SU HIJO ASISTIRÁ A (X) # De células Campo se cerrará el miércoles, 4 de Julio, en observancia del día de la independencia. Cuidado Fechas de Que asisten a ext. Junio al 22 de junio 25 al 29 de junio Julio Julio al 20 de julio Julio * SÓLO CUSTODIA GUARDIAN PUEDE ALTERAR LA FORMA Fecha de nacimiento
8 INFORMACIÓN DE CONTACTO PROVEEDOR PHYSICAIN O CUIDADO DE LA SALUD (REQUERIDO) Alergias: sí NO Lista: Restricciones físicas: sí NO Lista: PERSONAS AUTORIZADAS PARA FIRMAR ESTE NIÑO SOLICITAR UN FORMULARIO POR SEPARADO NOMBRES ADICIONALES SI ES NECESARIO. Tenga en cuenta que las personas que no tenemos autorización por escrito no podrán salir o sacar al niño de campamento bajo ninguna circunstancia. NO SE PERMITEN ADICIONES POR TELÉFONO. En la consideración de Okeechobee County Departamento de parques y recreación de prestación de servicios, equipo, instrucción y supervisión de este programa, los abajo firmantes padres del solicitante en el presente documento llamado hace por este medio: Y 1. Asumir todos los riesgos y responsabilidad por posibles daños o lesiones implicadas mediante la participación en este programa y entender la necesidad de proporcionar personalmente seguro en caso de lesiones. 2. Certifica que el solicitante nombrado en este documento está en buena salud y capaz de participar en este programa. 3. Beca Okeechobee County permiso para usar, copiar, exhibir, publicar o distribuir semejanza de mi hijo en una fotografía en y todos los medios de comunicación ahora conocido o en adelante conocido, incluidas las entradas de sitio web, sin el pago o cualquier otra consideración en perpetuidad. Entiendo y acepto que estos materiales pasarán a ser propiedad del Condado de Okeechobee y no serán devueltos. 4. de acuerdo en indemnizar y mantener inofensivo Okeechobee Condado departamentos o agentes de responsabilidad resultante de la participación del solicitante en el programa. Firma Fecha HOJA DE PERMISO Yo, doy mi permiso para impreso del padre o tutor impreso nombre de niño Participar en las actividades fuera del todo asociadas con el programa de verano. Firma Fecha 2018 jugar campamentos se llevan a cabo por Okeechobee Condado de parques y recreación, 1718 NW 9th Ave., Okeechobee, FL 34972, (863)
Jennifer Bellinger ORHS Principal. October 16, 2017
October 16, 2017 Dear Parent/Guardian of, Oak Ridge High School is dedicated to providing additional academic instruction designed to increase students academic achievement on grade level state standards.
Phelan Language Academy DUAL LANGUAGE IMMERSION Providing a World of opportunities for students DUAL LANGUAGE IMMERSION APPLICATION FORM
Phelan Language Academy DUAL LANGUAGE IMMERSION Providing a World of opportunities for students DUAL LANGUAGE IMMERSION APPLICATION FORM PLEASE NOTE: Applications need to be received by the due date and
WHCS. Washington Heights Choir School Escuela de Coro de Washington Heights. an after school program un programa después de la escuela
WHCS Washington Heights Choir School Escuela de Coro de Washington Heights an after school program un programa después de la escuela APPLICATION FORM FORMULARIO DE INSCRIPCIÓN Please print neatly and complete
Fresh Youth Initiatives Summer Day Camp "Taking Responsibility For Things That Matter REGISTRATION / REGISTRO 2013
Fresh Youth Initiatives Summer Day Camp "Taking Responsibility For Things That Matter FYI Main Office 505 W. 171 st Street New York, N.Y. 10032 Phone (212) 781-1113 Fax (212) 781-1151 www.freshyouth.org
Who: 3rd - 5th Where: TBD
Who: 3rd - 5th Where: TBD Tuesdays, 3:15 p.m. - 4:15 p.m. Feb 5th - Apr 2nd Cost: FREE Club Organizer: Claudia Ortiz claudia.ortiz@austinisd.org We are capped at 16 students Registration forms due Jan
Inspire.Innovate.Engage KINDERGARTEN PRE-REGISTRATION
1 2018-2019 KINDERGARTEN PRE-REGISTRATION Packet Must Be Returned By February 1 st, 2018 for Program Consideration District Office, Door A-2, 1936 Green Bay Rd, Highland Park, IL 60035 Monday Thursday
Sample Parental Consent Letters
Sample Parental Consent Letters 2015-16 The following links provide sample parental consent letters that clients are welcome to edit for their own purposes. Under applicable federal, state, and local laws,
RELEASE AND INDEMNIFICATION AGREEMENT (Adult Participant) The University of Texas at El Paso Department: Location: Date(s):
RELEASE AND INDEMNIFICATION AGREEMENT (Adult Participant) Participant: (Name and Address) University: The University of Texas at El Paso Department: Description of Activity or Trip: _ Location: Date(s):
Registration /Formulario de Inscripción
Catechesis of the Good Shepherd/Catequesis del Buen Pastor Registration 2017 2018/Formulario de Inscripción Family must be registered and actively involved in our Parish to be able to participate in our
Application for Admissions School Year: Class of 2020
For Office Use Only: Date Received: Administration Fr. Tom Schrader, President Ms. Karen Hopson, Principal Mr. Michael Beaven, Vice Principal/ Dean of Students 708 N. 18th Street Kansas City, KS 66102
WINTER RECREATIONAL LEAGUE SESSION II
WINTER RECREATIONAL LEAGUE SESSION II REGISTRATION FORM 2018 PLAYER LAST NAME: PLAYER FIRST NAME: PLAYER BIRTHDAY: SHIRT SIZE: HOME PHONE: CELL PHONE: STREET: TOWN NJ ZIP CODE: EMAIL DAD S NAME MOM S NAME
/ INSCRIPCIÓN / / REGISTRATION S /
c a m p u s d e v e r a n o v a l e n c i a 1 c a m p u s d e v e r a n o v a l e n c i a / INSCRIPCIÓN / / REGISTRATION S / / CAMPUS DE VERANO 2017 / / SUMMER CAMP 2017 / c a m p u s d e v e r a n o v
Current Grade Date of Birth / / Grade entering
Frontier School of Innovation 6700 Corporate Dr. Phone: 816-363-1907 (E): 816-241-6202 (MS) Fax: 816-363-1165 (E): 816-241-6207 (MS) http://www.kcfsi.org STUDENT INFORMATION Frontier STEM High School 6455
Vision and Hearing Program Consent for Services. I, the parent/legal guardian of, give consent Please print name of child
Vision and Hearing Program Consent for Services I, the parent/legal guardian of, give consent Please print name of child for the Cook County Department of Public Health to provide vision and/or hearing
Annual Latino Youth & Parent Leadership Conference for:
Annual Latino Youth & Parent Leadership Conference for: Leadership Skills Positive Self-Esteem Career Awareness Napa County 8th - 12th Grade Students & Parents Saturday, April 25, 2015 8:00 a.m. - 2:00
NUEVOS ESTUDIANTES PAQUETE DE INSCRIPCIÓN
BIENVENIDOS A PAVE SCHOOLS! NUEVOS ESTUDIANTES PAQUETE DE INSCRIPCIÓN Apellido Del Estudiante Primer Nombre Del Estudiante Fecha De Nacimiento Completar los formularios y presentar los documentos requeridos:
Identity and Statement of Educational Purpose Instruction Sheet
Identity and Statement of Educational Purpose Instruction Sheet You must appear in person at Midwestern State University Financial Aid Office (MSU-FAO) to present your governmentissued ID (such as driver
Employee s Injury Report / Informe de lesión de empleado
Claims Administrative Services Phone: 800-765-2412 Fax: 903-509-1888 501 Shelley Drive Claims Administrative Services, Inc. Tyler, Texas 75701 Our reputation for excellence is no accident. / Nuestro prestigio
Child s Full Name: School attending: Grade : Birthdate: Birthplace: Gender: M F
FAITH FORMATION REGISTRATION FORM 2016-2017 Family Name: Address: City: Zip Code: Home phone: Mom: Name: Maiden Name: Dad: Name: Cell: Cell: Email: Email: Children information Child s Full Name: School
violencia domestica? Si No Ciudad: Estado: Código Postal: Si hay problemas de violencia domestica, por favor diríjase a la sección #7f abajo.
Por favor escriba claramente con letra de molde dentro de la cuadricula: Información del solicitante: Soy la persona que proporciona cuidados o el padre que no tiene custodia 1. Información de la persona
Verification Worksheet V4 D I
Last Name: First Name: ID: (print clearly) 2018 2019 Verification Worksheet V4 D I Before your financial aid for the 2018/2019 award year can be finalized, federal regulations require that certain data
As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway!
June 2014 Dear Parents and Guardians: As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway! The District Summer School Program will operate
OCONEE COUNTY MENTOR PROGRAM. Permission Form Packet
OCONEE COUNTY MENTOR PROGRAM Permission Form Packet PARENT INFORMATION/EXPECTATIONS Your child has been selected to participate in the Oconee County Mentor Program. This program was established to provide
INTERNATIONAL ADMISSIONS
INTERNATIONAL ADMISSIONS ADMISIONES INTERNACIONALES IMPORTANT: ENTIRE APPLICATION MUST BE COMPLETED. PLEASE READ CAREFULLY. IMPORTANTE: SE DEBE COMPLETAR TODA LA SOLICITUD. FAVOR DE LEER CON DETENIMIENTO.
Windham Early College Opportunity Application for Admission
Windham Early College Opportunity Application for Admission Thank you for your interest in the Windham Early College Opportunity program at Windham High School. You may hand-deliver or mail the completed
Requesting Accommodations SAT and ACT. Sign and return the Parent permission form to the SSD Coordinator
Requesting Accommodations SAT and ACT SAT Sign and return the Parent permission form to the SSD Coordinator SSD Coordinator submits information online to College Board The deadline for accommodations approval
STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT
STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT This document is intended to address the McKinney-Vento Assistance Act. Your answers will help determine documents necessary to enroll your child quickly and determine
HIDALGO ISD GIFTED/TALENTED PROGRAM PUBLIC ANNOUNCEMENT OF REFERRAL PERIOD HIDALGO ISD PROGRAMA PARA ESTUDIANTES DOTADOS/TALENTOSOS
Public Notice HIDALGO ISD GIFTED/TALENTED PROGRAM PUBLIC ANNOUNCEMENT OF REFERRAL PERIOD Hidalgo is now accepting referrals for students who may need Gifted/Talented Services for the school year. This
Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años
Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años FREE GRATIS Beacon Programs Adult Enrollment Form Beacon PROGRAMS Participant Information
/ / Date of Birth/Fecha de nacimiento Grade/Grado escolar Home School/Escuela School Phone Number Teléfono de la escuela
Pleasantville Public Schools Garnell, Bailey, Ph. D Superintendent of Schools Combining Academics, Recreation & Enjoyment Pleasantville s 21 st. Century Community Learning Centers Gender: M F Student Name/
Old Mission San Juan Bautista Religious Education Registration Form Office Phone: (831)
Old Mission San Juan Bautista Religious Education Registration Form Office Phone: (831) 623 4178 faithformation@oldmissionsjb.org Today's Date: Amount Paid: Installments: RCIA: 1st Yr [ ] 2nd Yr [ ] 1st
TRENTON BOARD OF EDUCATION ''Children Come First, Los Niños son Primeros." Lucy Feria Micah Bradley-Freeman, MSN RN Interim Superintendent of School Supervisor of Nurses 609.656.4900 609.989.2682 fax lferia@trenton.k12.nj.us
Civil Rights Complaint Form
Civil Rights Complaint Form Title VI of the 1964 Civil Rights Act and related non-discrimination statutes and regulations require that no person in the United States shall, on the ground of race, color,
Por favor, utilice esta lista de verificación para asegurarse de que haya incluido todos los documentos solicitados.
Para que su solicitud sea considerada completa y revisada por el comité de becas, se requieren los siguientes documentos. Toda la información se mantendrá confidencial. Por favor, utilice esta lista de
2770 South Taylor Street Arlington, Virginia Phone: (703) STUDENT ATHLETE ACCIDENT INSURANCE COVERAGE
Arlington Public Schools FACILITIES AND OPERATIONS September 5, 2017 2770 South Taylor Street Arlington, Virginia 22206 Phone: (703) 228-7740 STUDENT ATHLETE ACCIDENT INSURANCE COVERAGE Dear Parent/Guardian,
Gender: Female Ethnicity: Birthdate: (Mon/Date/Year) (Number) (Street) (City) (Zip)
Application Form Due March 17 th, 2017 Student's Name (Last, First): Gender: Female Ethnicity: Birthdate: Male (Mon/Date/Year) Home Address: (Number) (Street) (City) (Zip) Phone Number: ( ) Alt. Phone
MYCHART PROXY ACCESS INFORMATION PAGE PÁGINA DE INFORMACIÓN PARA EL ACCESO DE REPRESENTANTE A MYCHART
FORMULARIO PARA EL ACCESSO DE REPRESENTANTE A MYCHART MYCHART PROXY ACCESS INFORMATION PAGE PÁGINA DE INFORMACIÓN PARA EL WHAT IS PROXY ACCESS? QUÉ ES UN ACCESO DE REPRESENTANTE? MyChart Proxy Access allows
Employer Employer Address Phone. Phone: Home Work Cell
PATIENT REGISTRATION Last Name First Name MI Date of Birth Age Social Security # Gender Marital Status Address Street Apt# City State Zip Phone: Home Work Cell E-Mail Occupation Retired: Yes No Employer
DOÑA ANA COUNTY HEAD START TOILET TRAINING PLAN LETTER TO PARENT
DOÑA ANA COUNTY HEAD START TOILET TRAINING PLAN LETTER TO PARENT : Child s Name: Center: Dear: Attached is a copy of the toilet training plan for your child which we will be using at the center. We are
NOTICE OF CHALLENGE OF APPLICATION
Section 13.074, Texas Election Code BW1-5, 01/2015 NOTICE OF CHALLENGE OF APPLICATION Notice is hereby given that your application for voter registration has been challenged pursuant to Sec. 13.074 Texas
Circuit Court for TRIBUNAL DE CIRCUITO DE
Circuit Court for TRIBUNAL DE CIRCUITO DE City or County (Ciudad o Condado) Case No. Name (Nombre) vs. (contra) Name (Nombre) Street Address (Dirección) Apt. # Street Address (Dirección) Apt. # City Ciudad
Winthrop High School SUMMER SCHOOL
Winthrop High School SUMMER SCHOOL Subjects Offered at Winthrop High School: English 9 & Algebra 1 Date of Courses: July 23 Aug 3, 2018 Location: Time: Winthrop High School 7:45 a.m. - 12:00p.m. Cost is
SPFA PCP - SPF ROOFING EXPERIENCE DECLARATION & PROJECT LIST (DECLARACIÓN DE EXPERIENCIA EN TECHUMBRES DE SPF Y LISTA DE PROYECTOS)
SPFA PCP - SPF ROOFING EXPERIENCE DECLARATION & PROJECT LIST (DECLARACIÓN DE EXPERIENCIA EN TECHUMBRES DE SPF Y LISTA DE PROYECTOS) 1) Please indicate your desired SPF certification goal: (Favor de indicar
Eligibility List (EL) Application
Division of Early Learning Services Early Care and Education Parent(s) Information First Name: Middle Initial (MI): Last Name : Male Female Male Female Birth Date: Work Phone: Cell/Message: E-mail: Married:
Informacion Basica de el paciente
Informacion Basica de el paciente Cash Fecha: Apellido: Nombre: Inicial: Direccion: Pueblo: Estado: Zip: Telefono de la casa o celular: Telefono del trabajo: Numero de seguro social: Fecha de nacimiento:
FERRIS INDEPENDENT SCHOOL DISTRICT NONRESIDENT STUDENT REQUEST TO TRANSFER INTO THE DISTRICT SCHOOL YEAR
FERRIS INDEPENDENT SCHOOL DISTRICT NRESIDENT STUDENT REQUEST TO TRANSFER INTO THE DISTRICT SCHOOL YEAR 2018-2019 1. STUDENT S NAME: 2. CURRENT ADDRESS: 3. SCHOOL DISTRICT IN WHICH THE STUDENT RESIDES:
Application Instructions for PARS 7 th September 8 12, 2008 Cuernavaca, Morelos, México
Application Instructions for PARS 7 th September 8 12, 2008 Cuernavaca, Morelos, México 1. Bank transfer registration fee (include Lodging, Transportation Airport-Hotel, Hotel-Airport and breakfast), before
Favor de cortar y mantenga esta página junto con nuestra información de contacto que aparece abajo. Gracias!
Please tear off and keep this page with our contact information below. Thank you! DEPARTMENT OF JUSTICE CRIME VICTIMS SERVICES DIVISION APPLICATION FOR CRIME VICTIM COMPENSATION You may qualify for help
Last Name: First Name: Middle Name: Age: (Apellido del estudiante) (Nombre) (Segundo Nombre)
OFFICE USE ONLY: Date: Grade in School 2018/19: FHC: 1 / 2 / Post RCIA DAY: TIME: Catechist: Paid in Full Yes No Cash Check # CC: New Student: Yes No Date on database: Staff Initials: Saturday: Sunday:
CAMP EDMO es un programa de Ciencia, Tecnología, Fabricantes, Recreación, y Habilidades. Makeropolis
DCYF 6 Week Camp Beca de 6 Scholarship Semanas Program CAMP EDMO es un programa de Ciencia, Tecnología, Fabricantes, Recreación, y Habilidades CAMP para EDMO la Vida is de an enriquecimiento Arts & Science,
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
Encl.: Teacher/Teacher Assistant Information Request Form
To: All Parents/Legal Guardians in Title I Schools From: Charlotte-Mecklenburg Schools Title I Department Date: September 27, 2017 Subject: Right to Know Notification to Parents of Teacher and Teacher
2018%19'School'Choice'&'Student'Transfer'Process' for'nathaniel'bowditch'students'and'families'(revised'3/14/18)'!
2018%19SchoolChoice&StudentTransferProcess fornathanielbowditchstudentsandfamilies(revised3/14/18) Identifying2018%19SchoolChoicesforYourChild Inordertoincreaseequityandaccessforallstudentsinourdistrict,SalemSchoolCommitteehasmadethe
Formulario de Postulación Universidad Católica Santo Toribio De Mogrovejo Estudiante de Intercambio Application Form / Exchange Student
Formulario de Postulación Universidad Católica Santo Toribio De Mogrovejo Estudiante de Intercambio Application Form / Exchange Student Información Personal Personal Information: Nombre FIrst Name Apellido
Applicant Last Name: First (Print clearly) Current Grade: (circle one):pre- K K September 2017 Grade
Application for Enrollment & Waitlist 2017-2018 Applicant Last Name: First (Print clearly) Current Grade: (circle one):pre- K K 1 2 3 4 5 September 2017 Grade Date of Birth Male[ ] Female[ ] School District
Civil Rights Complaint Form
Civil Rights Complaint Form It is the policy of the Greater Derry Salem Cooperative Alliance for Regional Transportation (CART) to uphold and assure full compliance with Title VI of the Civil Rights Act
City of Wilmington, Dennis P. Williams, Mayor Department of Parks and Recreation, James M. Lane, Director presents ENRICHMENT CAMP
City of Wilmington, Dennis P. Williams, Mayor Department of Parks and Recreation, James M. Lane, Director presents Summer ENRICHMENT CAMP JUNE 22 to AUG. 14, 2015 8:30 AM to 3:30 PM For Boys and Girls,
EXCHANGE STUDENT APPLICATION FORM
EXCHANGE STUDENT APPLICATION FORM (FORMULARIO DE INSCRIPCIÓN ESTUDIANTES DE INTERCAMBIO) Date of application: / / (Fecha de inscripción) (dd) (mm) (yy) Personal Data (Datos personales) Last names: (Apellidos)
PLEASE RETURN THIS SIGNED FORM TO OUR OFFICE, WE WILL MAKE YOU A COPY AND PLACE IT IN YOUR FAMILY FILE.
AGREEMENT 1. NON REFUNDABLE Registration fee of $100. 2. Full time Children s Center accounts are billed each month. Payment is due every 10th or 25th of the month. Each family is required to sign up Smart
Barbara Quaid. March 1, Dear Ventura County Teachers:
March 1, 2018 Dear Ventura County Teachers: The Ventura County Fair invites students to earn free carnival rides through our reading program, Read & Ride for local kindergarten through 8 th grade students.
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
Hojas de Inscripción Retiro Estatal de Jóvenes Hispanos 2016 Sept. 2 5, 2016 Centro de Conferencias Caswell 100 Caswell Rd, Oak Island, NC 28465
Hojas de Inscripción Retiro Estatal de Jóvenes Hispanos 2016 Sept. 2 5, 2016 Centro de Conferencias Caswell 100 Caswell Rd, Oak Island, NC 28465 Para uso de la oficina solamente: Día que se recibió Día
Delegación de Autoridad Parental (DOPA) Delegation of Parental Authority (DOPA)
Delegación de Autoridad Parental (DOPA) Delegation of Parental Authority (DOPA) Qué es una Delegación de Autoridad Parental (DOPA)? Una Delegación de Autoridad Parental (DOPA) es un documento que le permite
I, the. submits the. The Annual Guardianship Plan for the period beginning, El Informe anual de la tutela corresponde al periodo que se inicia el
IN THE CIRCUIT COURT FOR ORANGE COUNTY, FLORIDA PROBATE DIVISION / DIVISIÓN DE SUCESIONES IN RE: GUARDIAN ADVOCATE OF ASUNTO: CURADOR DE Case No /No. de causa: ANNUAL GUARDIAN ADVOCATE REPORT ANNUAL GUARDIAN
New Student/Parent Enrollment Instructions
New Student/Parent Enrollment Instructions Instruciones para Inscripción de Nuevo Estudiante/Padre al distrito 1) If you don t have a Skyward user id and password and have never had a student at LISD,
Polk School District
May 16, 2016 Dear Parent/Guardian: Dr. William A. Hunter, Superintendent 612 S College Street Cedartown, GA 30125 770.748.3821 www.polk.k12.ga.us As the parent or guardian of a student currently enrolled
Instituto de Liderazgo Hispano Iniciativa de Líderes de Escuela Secundaria
Instituto de Liderazgo Hispano Iniciativa de Líderes de Escuela Secundaria Construyendo el camino para los líderes de mañana. Patrocinador Titular FORMULARIO PARA ESTUDIANTE Instituto de Liderazgo Hispano
Fax COMPLETED Shoe Charts to
SHOE CHART Make blank copies of this form Complete one chart for each class and include start time Indicate number of charts per class I.E. of - of Use whole sizes only - Boys same size Girls down one
2018 SCHOLARSHIP APPLICATION
Page 1 2018 SCHOLARSHIP APPLICATION PART 1: PERSONAL INFORMATION Name Date of Birth Country of Birth How long in U.S. In N.C. Address Phone Email Please select your preferred method of contact if selected
Delegación de Autoridad Parental (DOPA) Delegation of Parental Authority (DOPA)
Delegación de Autoridad Parental (DOPA) Delegation of Parental Authority (DOPA) Qué es una Delegación de Autoridad Parental (DOPA)? Una Delegación de Autoridad Parental (DOPA) es un documento que le permite
Consentimiento informado para la evaluación neuropsicológica y el tratamiento psicológico
Rosalia Pereyra-Quiroz, Psy.D., MBA Clinical Psychologist Phoenix, AZ. 85020 (602) 314 4475 Fax (602) 368 3424 Consentimiento informado para la evaluación neuropsicológica y el tratamiento psicológico
COMPACT FOR SCHOOL PROGRESS THROUGH PARENT INVOLVEMENT
COMPACT FOR SCHOOL PROGRESS THROUGH PARENT INVOLVEMENT COMPLETE THIS FORM AND INCLUDE IT WITH THE POLICY FOR YOUR SCHOOL. SCHOOL-PARENT COMPACT The name of school, and the parents of the students participating
Frederick News May 25 th, 2018
Frederick News May 25 th, 2018 Yearbooks If your child purchased a yearbook, they will be distributed on Tuesday, May 29 th. Extra yearbooks will then be sold in the office for $20 starting 5/30 while
LONG BEACH UNIFIED SCHOOL DISTRICT
LONG BEACH UNIFIED SCHOOL DISTRICT Parent/Guardian Complaint Concerning District Personnel Pursuant to Education Code Section 35160.5, the District has a carefully defined procedure for processing complaints
Transitional Kindergarten Program Parent Request
Date Received: / / Time Received: am / pm FOR OFFICE USE ONLY Transitional Kindergarten Program Parent Request Child s Name: (Please Print) First Middle Last Birth Date: / / Sex: M F Month Day Year Home
DOES YOUR CHILD HAVE ASTHMA? No STOP HERE Yes Please complete this form
DOES YOUR CHILD HAVE ASTHMA? No STOP HERE Yes Please complete this form If you have any questions, please contact your child s school nurse. Date form completed: Student ID Student Name: Birth date: Parent/Guardian
Home Access Center Matriculación Electrónica Verificación Del Estudiante
Home Access Center Matriculación Electrónica Verificación Del Estudiante Los padres o tutores que tienen una cuenta de correo electrónico existente en los archives de la escuela de su hijo/a recibirán
Boys & Girls Club of Newburgh 285 Liberty Street, Newburgh NY Phone: (845)
Boys & Girls Club of Newburgh 285 Liberty Street, Newburgh NY 12550 Phone: (845) 561-4936 www.bgcnny.org SmARTS Summer Program Application Returning Club Members ONLY *Parent/Guardian: This form is an
I am the parent or legal guardian of.
EXHIBIT Descriptive Code: IFCB-R/E (2) FIELD TRIPS AND EXCURSIONS Date: March 9, 2006 Clarke County School District Student Travel Authorization and Teacher ation Form To SCHOOL: I am the parent or legal
Welcome to the CU at School Savings Program!
Welcome to the CU at School Savings Program! Thank you for your interest in Yolo Federal Credit Union s CU at School savings program. This packet of information has everything you need to sign your child
April Workshops. Community Resource Connection - English Only. Environmental Rating Scale Introduction - English Only
April Workshops Community Resource Connection - English Only I Saturday I 4.7.2018 I 9:00am 12:00pm I $10/per person Come and gather information about the resources available to families and child care
Action Required by September 30, 2018 in order to Participate as a Provider in the Puerto Rico Medicaid Government Health Plan Program
CIRCULAR LETTER #M1807134 September 15, 2018 Action Required by September 30, 2018 in order to Participate as a Provider in the Puerto Rico Medicaid Government Health Plan Program Dear Provider, Greetings
Reclaim Your Future: It s Not Too Late to Graduate
Reclaim Your Future: It s Not Too Late to Graduate Campaign Saturday, September 7, 2013 from 8:00 a.m. to 1:00 p.m. VOLUNTEER SHEET Please print: Contact Name Mailing Address City State Zip Business/Organization
OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal.
OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. For Clerk s Use Only Name of Person Filing: (Nombre
Harden Middle School AVID APPLICATION
Incoming 7 th Date Submitted: Time: Person at HMS who received it: Harden Middle School AVID APPLICATION Your student is being recommended to participate in the AVID program at Harden Middle School. AVID
HEAD START MEDICATION ADMINISTRATION
HEAD START MEDICATION ADMINISTRATION Dear Parents/Guardians: It is the policy of Head Start to cooperate with each Head Start child's parent/guardian and his/her physician by administering and providing
LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT EMERGENCY INFORMATION FORM Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain
PROCEEDS FROM THE WALK-A-THON WILL BENEFIT BREAST CANCER, LEUKEMIA, SICKLE CELL ANEMIA AND UFCW LOCAL 888 SCHOLARSHIP FUND
PROCEEDS FROM THE WALK-A-THON WILL BENEFIT BREAST CANCER, LEUKEMIA, SICKLE CELL ANEMIA AND UFCW LOCAL 888 SCHOLARSHIP FUND Date: Sunday, September 18, 2016 (Rain or Shine) Registration Time: 8:30 a.m.
STUDENT ACTIVITIES. Permission Form for School Year Activities for a Specific Group (Spanish
The forms on the following pages shall be used by the District for student travel: Exhibit A: Exhibit B: Exhibit C: Exhibit D: Exhibit E: Exhibit F: Exhibit G: Permission Form for Field Trips (English