Eighth Graders Israel Experience May APPLICATION

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Eighth Graders Israel Experience May 7-19- 2014 APPLICATION"

Transcription

1 please attach photo Part I: Applicant Information Eighth Graders Israel Experience May APPLICATION Applicant's name (As appears on passport) Last first middle what do you want to be called? Parents'/guardians' names Mailing address Number & street city zip Second mailing address (if parents do not live together) Number & street city zip Home Telephones Parent's day phone: Mother Father will be the primary means of communication both before and during the trip. Please provide all addresses through which we can reliably contact you and your parent/guardian(s): Parent's Mother Father Teen's Date of birth Male o Female o 1

2 Passport Passports: We must have the number of your valid U.S. and, if you have one, Israeli passport. o Passport # Please include a copy of the picture page of the passport. Please make certain that your U.S. passport does not expire until at least SIX MONTHS after the conclusion of the trip! o I will apply for a U.S. passport immediately, and inform you of the name and number as soon as I receive it. IF YOU HAVE AN ISRAELI PASSPORT, YOU MUST BRING IT. o I have a valid Israeli passport #. Please make certain that your Israeli passport does not expire until at least SIX MONTHS after the conclusion of the trip! Please include a copy of the picture page of the passport. Anything else you would like to tell us? 2

3 MEDICAL HISTORY & INFORMATION (To be completed by participant's parents) Participant's Name 1. Is your child a vegetarian? Yes o No o 2. Are there any foods to which your child is allergic? 3. Are there any restrictions on his/her physical activities? 4. Are there any medications or shots that he/she takes regularly? 5. Is there any medication to which he/she is allergic? 6. Physical problems or limitations do not necessarily disqualify a student from participation in the program. However, we must be aware of all conditions in order to plan adequately for your child's well being on the trip. Are there any physical limitations of which our staff should be aware to insure the safety and comfort of your child in this program? 7. It is our experience that more and more people are availing themselves of the services of psychiatrists, psychologists, and counselors to deal with emotional difficulties. Our policy is not to disqualify youths with emotional problems as long as it is the opinion of the staff that the student can function in a program such as ours. A candid description of past, present and potential emotional difficulties will be kept confidential and will enable our Israel staff to work intelligently and sensitively with your child should any unexpected problem arise. It is vital for the safety and comfort of both your child and your child s companions that you be honest and forthcoming with us about potential emotional problems. a) Has your child ever had psychological or drug/alcohol related problems? If yes, please explain. b) Has your child ever had psychological or drug/alcohol counseling or treatment? If yes, please explain. c) Has your child ever been hospitalized for emotional or drug/alcohol related problems? 3

4 d) Please give full name, address and phone number of professional(s) who have treated your child. 8. Please use another sheet for additional comments or notification of restrictions. PARENTS ACKNOWLEDGMENT AND AUTHORIZATION This health history is correct so far as I know, and the person herein described has permission to engage in all trip activities, except as noted by me and by the examining physician. I understand that failure to reveal physical or emotional conditions that may affect my child s ability to participate fully in trip activities may result in my child being sent home early at the discretion of the Trip Leader, at my expense and without possibility of reimbursement of trip costs. In the event of an emergency, after an effort has been made to contact the parents, guardian, or those listed in the North American Emergency Contact Form, I hereby give permission to the physician selected by The Israel Experience Educational Tourism Services Ltd. and S.S.D.S representative to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. Participant's Name Parent's Signature PHOTO RELEASE I understand that my child may be included in photographs and video footage that may be filmed during the trip. I authorize the The Israel Experience Educational Tourism Services Ltd. and to use these photos/video to promote its programs and services in print, web, and other promotional contexts. Participant s Parents: All parents/legal guardians must sign. Dated: signed: print: Dated: signed: print: Participant: Dated: signed: print: Participant's name 4

5 Part II: Statement of Responsibility of Program to Participant Jewish Experience in Israel, through its sponsoring organization agrees to: 1. Provide full-time professional supervision and leadership from the time the group departs school until it returns, in order to insure the safety, well being and enjoyment of program participants. 2. Design all program elements in order to conform to the standards of kashrut and to an appropriate observance of the Sabbath. 3. Establish and enforce those rules and expectations necessary to ensure the safety and well being of program participants. 4. Sponsor pre-trip orientation meetings to prepare participants for the program, and to answer any questions that parents might have. 5. Keep parents advised as to the progress of the group during the course of the trip and to promote regular communication between participants and families. Part III: Applicant's Contract/Rules and Responsibilities The following rules have been established to ensure the health and safety of all participants in Jewish Experience in Israel. The applicant agrees to: 1. Conduct him/herself in a manner that reflects well on S.S.D.S & the Jewish community, both while in Israel and while in transit. 2. Participate in all program activities, including mandatory pre-trip sessions. (In case of accident or illness, the applicant or the parent/guardian will notify a staff person immediately.) 3. Property used by the program is not to be abused or defaced in any way. Damage must be paid for by the individual responsible. 4. Conduct him/herself in a manner that does not in any way - whether physically, verbally, emotionally, or otherwise - violate the privacy or well being of another individual. 5. Possession or use of alcoholic beverages or illegal drugs by program participants is absolutely forbidden and will result in immediate suspension and will be grounds for being sent home. 6. The Israel Experience Educational Tourism Services Ltd., in consultation with S.S.D.S will have the sole authority to decide whether the participant, as a result of inappropriate behavior, should be returned to the U.S. ahead of time. I have read and understood these rules and agree to uphold them. I further understand that failure to comply with these rules may result in my being sent home early from the program at my parents expense. Applicant s Signature Date Parent/Guardian's Statement: 1. I have read and discussed these rules and expectations with my child and understand that the Program Director retains the right to arrange for early return home should he/she engage in behavior which is grossly inappropriate and which jeopardizes the health or well-being of program participants or him/herself. I further understand that early separation from the program may result in special airfare charges, as a result of deviation from the group schedule and fares, and agree to accept responsibility for any such special charges. These charges will also apply should my child be returned home early for medical reasons that were not disclosed to us prior to the trip. Signature of Parent/ Guardian Date 5

6 RELEASE AND WAIVER OF LIABILITY and are the parents of (Mother) (Father) (the teen. ) We understand that this Release and Waiver of Liability is an important document related to the teen s participation in Jewish Experience S.S.D.S (the trip ). We are aware that by signing this document, we are releasing potential claims against the trip s sponsors and others involved either directly or indirectly from liability that may arise as a result of accident or unforeseen events during the trip. We acknowledge that trip activities, including but not limited to hiking, rafting, snorkeling, swimming, camping, bus, jeep and air travel, may be subject to certain hazards, both natural and man made; and further that the teen is voluntarily participating in the trip and these activities with our knowledge, appreciation, and understanding of the dangers and risks involved. We hereby agree to accept any and all risks of the teen participating in the trip. We understand the value of a trip to Israel and further understand that the trip sponsors cannot bear or accept liability for the potential hazards that could, if such were to occur, subject trip sponsors to potential claims. We therefore agree that we, our heirs, next of kin, guardians, successors and assigns, and any other representative of ours will not sue, claim against, attach the property of or prosecute any of The Israel Experience Educational Tourism Services Ltd., and S.S.D.S its directors, officers, agents and employees, and all affiliated entities for loss of property, injury, harm, accident, illness, loss of limb or life, or other personal injury, incapacity, medical cost, expense, damage, claim, liability, howsoever caused, and regardless of whether caused directly or indirectly, by their acts or any other acts, arising out of or in connection with the teen s participation in the trip or activities associated with the trip. Participant: Dated: Signed: print: Participant s Parents: All parents/legal guardians must sign. Dated: Signed: print: Dated: Signed: print: Dated: Signed: print: Dated: Signed: print: 6

7 EMERGENCY INFORMATION Participant's name Shalom! If you can be contacted at your regular home and work numbers during the entire trip, there is no need for you to fill in Part 1 of this page. However, if you will be away from your regular numbers please give us details of how you can be contacted. 1. On the following dates we will not be at home or at work and can be contacted, in the case of emergency, at: From / /10 to / /10 Tel: ( ) From / /10 to / /10 Tel: ( ) From / /10 to / /10 Tel: ( ) From / /10 to / /10 Tel: ( ) In the event that we, the parents/guardians, cannot be contacted, you may obtain emergency permission regarding our son or daughter from: In Israel (if available) In USA Name Relationship Address Home Phone Business Phone Mobile Phone 7

8 MEDICAL EXAMINATION BY PHYSICIAN Participant's Name To be completed by a licensed physician This examination MUST be performed within twelve (12) months of departure for Israel. Examination for some other purpose within this period is acceptable. CODE: ü Satisfactory; X Not satisfactory; 0 Not examined (If not satisfactory, please explain). Height Ears Hernia Weight Nose Extremities B.P. Throat Posture (spine) Hgb. Test Teeth Skin Urinalysis Heart Allergies: Please specify Eyes Lungs Glasses Abdomen General Appraisal: (For females) Has this person menstruated? Yes o No o Is her menstrual history normal? Yes o No o Special considerations? Recommendations and restrictions while in Israel: Dietary Restrictions Swimming, diving Exposure to sun and extreme heat Strenuous activity (mountain climbing, hiking, etc.) Other Is there any history of emotional disturbance in applicant? Yes o No o Has he/she shown any of the following: a. Difficulties in relationships with parents, authority figures, persons of his/her own age? Yes o No o b. Behavior disorders Yes o No o c. Emotional symptoms such as mood swings, depression, sleep disorders, unusual degree of anxiety, fear or guilt? Yes o No o Please explain 8

9 d. Has the applicant been to a psychiatrist within the last 4 years? Yes o No o If yes, permission is requested for a confidential report from the psychiatrist(s) to be sent to our office. e. Is there any congenital malformation now existing that may require special treatment or consideration? Yes o No o If yes, please explain. f. To your knowledge, is there any history of medical, emotional, or drug/alcohol-related problem? Yes o No o If yes, please explain. I have examined the person herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in the program's activities except as noted above. Examining Physician (print) Examining Physician (sign) Address Date (print) MUST BE DATED! State, Zip Code Area Code and Phone Number **NOTE: All medication must be indicated on the attached medication form. 9

10 Solomon Schechter Day School 8 th Grade Israel Trip 2014 MEDICATION FORM This medication form MUST be completed by a parent and SIGNED BY YOUR PHYSICIAN if your child requires any medication. YOU MUST SEND ALL MEDICATION* one week prior to departure If your child requires ANY medication INCLUDING TYLENOL, INHALERS, EPIPENS, ETC. you and your physician must complete and sign this medication permission slip. *Medicine must be sent in ORIGINAL PHARMACY CONTAINER with the PATIENT S NAME, PHYSICIAN S NAME, NAME OF MEDICATION, DOSAGE AND TIME IT IS TO BE TAKEN. The above rules apply to all medications including Tylenol, inhalers, epipens, etc. STUDENT S NAME (please print) Medication #1 Dosage Time Frequency # of Days Condition for which medication has been prescribed Possible side effects Special instructions_ Medication #2 Dosage Time Frequency # of Days Condition for which medication has been prescribed Possible side effects Special instructions_ Medication #3 Dosage Time Frequency # of Days Condition for which medication has been prescribed Possible side effects Special instructions_ Physician s name and phone (please print) Parent name and phone (please print) PARENT S SIGNATURE DATE PHYSICIAN S SIGNATURE DATE

HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS

HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS HOUGHTON COLLEGE & CSEHY SUMMER SCHOOL OF MUSIC MEDICAL RECORD & WAIVER FORMS COMPLETION AND RETURN OF THIS FORM TO THE CAMP DIRECTORS IS REQUIRED FOR ADMISSION TO CAMP. Either Mail This Completed Form

More information

Winter Camp 2015 Church Registration Instructions and Policies

Winter Camp 2015 Church Registration Instructions and Policies Winter Camp 2015 Church Registration Instructions and Policies Registration Instructions: 1) Choose your weekend(s). Prayerfully consider which available weekend is the best for your church. Bring your

More information

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM Branch: North Brooklyn YMCA Camp Site: North Brooklyn Branch Camp Type: PARTICIPANT INFO Child s Name Age D.O.B. Gender Grade in September 2016 School

More information

Student & Health Information for Bates College Off-Campus Short Term Courses

Student & Health Information for Bates College Off-Campus Short Term Courses Student & Health Information for Bates College Off-Campus Short Term Courses 1. Name Program/Course Bates ID # Email Cell phone: Home Address: Date of Birth Nationality If course is going abroad, attach

More information

THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP

THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP 2011 SUMMER FASHION PROGRAM STUDENT APPLICATION CHECKLIST To apply for the Summer Fashion Program, please submit the required documents to The Center for Global

More information

Compass Road to College Summer Tour Application

Compass Road to College Summer Tour Application Compass Road to College Summer Tour Application Student Information Name: Email Address: Sex: F M Birth Date: Primary Language Spoken at Home: English Spanish Other: Current School: School You ll be Attending

More information

UNIVERSITY OF CONNECTICUT UNDERGRADUTE EDUCATION FIELD TRIP POLICY

UNIVERSITY OF CONNECTICUT UNDERGRADUTE EDUCATION FIELD TRIP POLICY Field Trips are an important component of the experiential learning advocated in the University s academic plan for undergraduate education. In order to promote the success and safety of all involved in

More information

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes)

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes) Robert D. Fowler Family YMCA Middle School Enrichment Program Student Registration Form 2015-16 Ivy Prep Academy Program Hours: 7am-7:45am & 4pm-7pm Transportation AM: Group leaves at 7:30am Transportation

More information

SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016

SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016 SMOKY MOUNTAIN CHRISTIAN CAMP REGISTRATION SUMMER 2016 Student s Name: Grade Entering: Date of Birth: / / Gender Male Female Address: City, State, Zip: Home Phone ( ) Email: Parent s Name(s): *Parent s

More information

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home

More information

Application Form. Executive MBA

Application Form. Executive MBA Department of Business Administration The International School Application Form Executive MBA Instructions All of the following materials must be submitted before your application will be processed: Application

More information

Youth Programs Registration Form Summer of Service (SOS) 2015

Youth Programs Registration Form Summer of Service (SOS) 2015 Youth Programs Registration Form Summer of Service (SOS) 2015 Participant s Information PHONE GENDER: FEMALE OF BIRTH SCHOOL GRADE IN FALL 2015 MALE ETHNIC BACKGROUND AFRICAN ASIAN INDIAN LATINO NATIVE

More information

HEALTH INFORMATION FORM FOR STUDY ABROAD PARTICIPANTS

HEALTH INFORMATION FORM FOR STUDY ABROAD PARTICIPANTS HEALTH INFORMATION FORM FOR STUDY ABROAD PARTICIPANTS Student: Last name: First Name: Middle Initial: Period of intended study abroad: Year(s): Fall Spring Academic Year Country Foreign Institution or

More information

GUATEMALA SURGERY TRIP Youth Volunteer Information and Release Form

GUATEMALA SURGERY TRIP Youth Volunteer Information and Release Form Team Name: Guatemala Surgery Travel Dates GUATEMALA SURGERY TRIP Youth Volunteer Information and Release Form Please complete this entire form, including the release and liability form and return immediately.

More information

TEXAS A&M INTERNATIONAL UNIVERSITY

TEXAS A&M INTERNATIONAL UNIVERSITY AGREEMENT FOR WAIVER, INDEMNIFICATION, ASSUMPTION OF RISK AND MEDICAL TREATMENT AUTHORIZATION I,, age, desire to participate voluntarily in all activities of the ( Activity ), which is sponsored or conducted

More information

Oberlin Dance Intensive

Oberlin Dance Intensive Oberlin Dance Intensive July 6-11, 2014 For Ages 14-18 Early Registration Deadline: March 1, 2014 = $585 tuition Regular Registration Deadline: April 10, 2014 = $625 tuition Email completed registration

More information

Youth Camp Civic Center

Youth Camp Civic Center Youth Camp Civic Center Household ID # Please circle the session(s) that your child(ren) will attend Session One June 8- June 12 Session Two June 15 June 19 Session Three June 22 June 26 Session Four June

More information

Backcountry Outdoor Adventure Camp

Backcountry Outdoor Adventure Camp Backcountry Outdoor Adventure Camp Get outdoors. Connect with nature. Focused on combining a passion for biology, conservation, and ecology with outdoor recreation. Registration Packet is due by: Registration

More information

Community House High School Programs Standing with families since 1969

Community House High School Programs Standing with families since 1969 Dear Parents/Guardians, Founded in 1969, Community House is devoted to standing with Princeton families by providing tools for academic success and social- emotional wellness through programs that bolster

More information

TOWN OF POUGHKEEPSIE POLICE DEPARTMENT

TOWN OF POUGHKEEPSIE POLICE DEPARTMENT TOWN OF POUGHKEEPSIE POLICE DEPARTMENT INFORMATION PACKET OVERVIEW The Town of Poughkeepsie Police Department is seeking to provide an innovative program for youth residing in the Town of Poughkeepsie.

More information

Elk Grove Park District Preschool Date

Elk Grove Park District Preschool Date Class For Office Use Only New/Readmit Birth Cert. In/Out of Dist Release Medical Elk Grove Park District Preschool Date Name of Child M F Date of Birth Age Primary Phone # Address City Zip Primary e-mail:

More information

INTERNATIONAL LEADERSHIP OF TEXAS

INTERNATIONAL LEADERSHIP OF TEXAS INTERNATIONAL LEADERSHIP OF TEXAS ACKNOWLEDGMENT OF RISK, INDEMNITY, WAIVER AND RELEASE OF LIABILITY AGREEMENT, NOTICE OF FINANCIAL RESPONSIBILITY, AND MEDICAL AUTHORIZATION & INFORMATION FORM IN WITNESS

More information

YOUTH MENTORING PROGRAM. Mentee Application (To Be Completed by the Parent/Guardian)

YOUTH MENTORING PROGRAM. Mentee Application (To Be Completed by the Parent/Guardian) Personal Information YOUTH MENTORING PROGRAM Mentee Application (To Be Completed by the Parent/Guardian) Youth s Name: Date: Parent/Guardian Name: Relationship to Youth: Mother Father Other, specify: Street

More information

PARTICIPANT AGREEMENT RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

PARTICIPANT AGREEMENT RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT PARTICIPANT AGREEMENT RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT I, the undersigned, on behalf of my minor child: ( Participant ), hereby acknowledge that Participant has

More information

Math + Leadership Camp at CSUSM Registration Forms

Math + Leadership Camp at CSUSM Registration Forms Math + Leadership Camp at CSUSM Registration Forms CONTACT INFORMATION Math for America San Diego Email: sandiego@mathforamerica.org Phone: 858-822-6284 Registration Checklist Complete all sections of

More information

2015 ADF School Medical/Insurance Information & Liability Waivers INSURANCE INFORMATION

2015 ADF School Medical/Insurance Information & Liability Waivers INSURANCE INFORMATION These forms must be completed and signed in all appropriate places by the participant, the participant s physician, and if under age 18, by the participant s legal guardian. The medical information we

More information

STEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire.

STEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire. New Rising Star Missionary Baptist Church Rising Stars Enrichment Program Registration Packet 7400 London Avenue, Eastlake Birmingham, Alabama 35206 Phone: (205) 833-3676 Email Address: risingstarscamp@nrschurch.org

More information

WOODWARD ACADEMY S STUDENT SUBSTANCE ABUSE TESTING POLICY

WOODWARD ACADEMY S STUDENT SUBSTANCE ABUSE TESTING POLICY Philosophy: WOODWARD ACADEMY S STUDENT SUBSTANCE ABUSE TESTING POLICY Woodward Academy is committed to fostering a drug free environment for students. Due to the prevalence of drugs in society, Woodward

More information

ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014

ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014 ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014 Completion of this application does not necessarily guarantee a place on the mission trip. Each application will be reviewed by the Missions Director and/or

More information

Milford Academy Admissions Office P.O. Box 878, New Berlin, NY 13411 Tel: (607) 847-9260 Fax: (607) 847-9250 www.milfordacademy.

Milford Academy Admissions Office P.O. Box 878, New Berlin, NY 13411 Tel: (607) 847-9260 Fax: (607) 847-9250 www.milfordacademy. Milford Academy Admissions Office P.O. Box 878, New Berlin, NY 13411 Tel: (607) 847-9260 Fax: (607) 847-9250 www.milfordacademy.org Health Insurance Information Notification (Please Print) This is to inform

More information

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478

More information

KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION

KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance

More information

Important Information Please keep this page for your records

Important Information Please keep this page for your records Camp Horizon Important Information Please keep this page for your records 1. Complete the enclosed application and the scholarship form thoroughly. Mail them immediately to the camp address listed below.

More information

Health Form Instructions

Health Form Instructions Health Form Instructions 888 272-7881 Fax 802 258-3509 studyabroad@sit.edu www.sit.edu/studyabroad The Health Form must be submitted within TWO WEEKS of offer of admission. If this is not possible, then

More information

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete

More information

GENERAL RECOMMENDATION

GENERAL RECOMMENDATION GENERAL RECOMMENDATION Release Authorization Your application will be held until we receive this form. RELEASE AUTHORIZATION To Be Completed by Student Student Signature Student Name Address t/ y/ e/zip)

More information

POLICY 5290. Student Discipline - Drugs/Alcohol/Tobacco

POLICY 5290. Student Discipline - Drugs/Alcohol/Tobacco A. Authority POLICY 5290 Student Discipline - Drugs/Alcohol/Tobacco The Box Elder School District Board of Education recognizes that the use, possession, distribution, or sale of tobacco, nicotine (including

More information

Thank you for your interest in the Illinois Association for College Admission Counseling s 2015 CAMP COLLEGE program!

Thank you for your interest in the Illinois Association for College Admission Counseling s 2015 CAMP COLLEGE program! Greetings! Thank you for your interest in the Illinois Association for College Admission Counseling s 2015 CAMP COLLEGE program! These waiver forms must be completed and submitted in order for your application

More information

Hours of Operation Monday Thursday 5 to 8 p.m.

Hours of Operation Monday Thursday 5 to 8 p.m. The Jerry Ortiz Memorial Boxing & Youth Fitness Gym is dedicated to enriching the quality of life for children and at-risk youth in the San Gabriel Valley area by promoting physical activity and good sportsmanship

More information

Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015

Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. Date of Program Please print in ink or type, and

More information

FUN IN THE SUN SUMMER DAY CAMP BEHAVIORAL CONTRACT

FUN IN THE SUN SUMMER DAY CAMP BEHAVIORAL CONTRACT FUN IN THE SUN SUMMER DAY CAMP BEHAVIORAL CONTRACT This contract is to be signed by both the participant (child) and his or her parent/guardian. This ensures that both the child and the adult understand

More information

Hornets Youth Enrichment Summer Program 1200 North DuPont Highway Dover, Delaware 19901 Telephone: 302-857-6824 Fax: 302-857-6823

Hornets Youth Enrichment Summer Program 1200 North DuPont Highway Dover, Delaware 19901 Telephone: 302-857-6824 Fax: 302-857-6823 Hornets Youth Enrichment Summer Program 1200 North DuPont Highway Dover, Delaware 19901 Telephone: 302-857-6824 Fax: 302-857-6823 Participant Last Name: Participant First Name: Grade: Age: Gender: Male

More information

GLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR 2015-2016 SCHOOL YEAR

GLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR 2015-2016 SCHOOL YEAR GLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR 2015-2016 SCHOOL YEAR Welcome Child s Enrollment Form Parent Pick-Up Authorization Emergency Information, Waiver & Medical

More information

Cassidy s Cause Therapeutic Riding Academy 6075 Clinton Rd Paducah, KY 42001 270-554-4040

Cassidy s Cause Therapeutic Riding Academy 6075 Clinton Rd Paducah, KY 42001 270-554-4040 VOLUNTEER / INTERN APPLICATION 2014 Thank you for your interest in volunteering with Cassidy s Cause! Our volunteers are the backbone of our program and without them our riders could not ride. Please complete

More information

Eagle Flight Squadron Inc. Youth in Aviation

Eagle Flight Squadron Inc. Youth in Aviation Eagle Flight Squadron Inc. Youth in Aviation Rev. Russell White / CEO 410 Springdale Avenue Office: (973) 674-3580 East Orange, NJ 07017 Home: (973) 672-4332 Fax: (973) 674-7760 AND BE LOOK UP LOOKED UP

More information

2015 FUMC Hurst Youth Missions: SAN ANTONIO Permission, Liability Waiver, and Medical Release Form

2015 FUMC Hurst Youth Missions: SAN ANTONIO Permission, Liability Waiver, and Medical Release Form Permission, Liability Waiver, and Medical Release Form I give permission to participate in activities of the Youth or Children s Division of the First United Methodist Church, Hurst, Texas for the dates

More information

Camper Information Form

Camper Information Form Camper Information Form NO CAMP HELD ON JULY 4, 2016 Please Mark Dates Attending: Session 1: June 27 July 8 Session 2: July 11 July 22 Session 3: July 25 August 5 ALL 3 SESSIONS Personal Information Name

More information

Georgia Tech North Ave. NW Atlanta Ga. 30332

Georgia Tech North Ave. NW Atlanta Ga. 30332 Welcome to Fun Weird STEM Saturdays 2014 The functioning objective of Fun Weird Science STEM Saturdays is to: 1. Provide students with hands-on STEM experience; and 2. Engage students in the exciting ways

More information

ESTACADA SCHOOL DISTRICT 108 STUDENT DRUG AND ALCOHOL PREVENTION PLAN

ESTACADA SCHOOL DISTRICT 108 STUDENT DRUG AND ALCOHOL PREVENTION PLAN ESTACADA SCHOOL DISTRICT 108 STUDENT DRUG AND ALCOHOL PREVENTION PLAN OREGON ADMINISTRATIVE REGULATIONS 581-022-0413 INTRODUCTION Estacada School District #108 has as its three year plan the development

More information

Jacob s Ladder Pediatric Rehabilitation Center, Inc. Child Respite Program

Jacob s Ladder Pediatric Rehabilitation Center, Inc. Child Respite Program Page 1 of 5 Intake Sheet Child s Name #1 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Child s Name #2 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Father/Mother/Guardian:

More information

Fort Vermilion School Division No. 52

Fort Vermilion School Division No. 52 P.O. Bag 1 (5213 River Road) Fort Vermilion, AB T0H 1N0 Phone: 780-927-3766 Fax: 780-927-4625 STUDENT INFORMATION REGISTRATION FORM Student s Legal Name: Last First Middle Student s Preferred Name: (if

More information

Medical Information. Page 1 of 5. Emergency Contact (other than Parent/Guardian): Name (First): Name (Last): Birth date: Age: Sex:

Medical Information. Page 1 of 5. Emergency Contact (other than Parent/Guardian): Name (First): Name (Last): Birth date: Age: Sex: Medical Information Name (First): Name (Last): Birth date: Age: Sex: Parent or guardian: Home Relationship to camper: Second Parent or guardian (or spouse): Home Relationship to camper: Emergency Contact

More information

(must be completed by a parent/guardian)

(must be completed by a parent/guardian) Indiana University Jacobs School of Music Tanguero Workshop MEDICAL WELLNESS FORM 2016 (must be completed by a parent/guardian) The Jacobs School of Music takes many precautions in an effort to ensure

More information

PROJECT EXCEL MENTORING PROGRAM Creating Vision Through Mentoring / What They See is What They Will Be

PROJECT EXCEL MENTORING PROGRAM Creating Vision Through Mentoring / What They See is What They Will Be Personal Information Mentee Application (To Be Completed by the Parent/Guardian) Youth s Name: Date: Parent/Guardian Name: Relationship to Youth: Mother Father other, specify: Street Address: City: State:

More information

State of California Governor s Office of Emergency Services MEDICAL REPORT: SUSPECTED CHILD PHYSICAL ABUSE AND NEGLECT EXAMINATION OES 900

State of California Governor s Office of Emergency Services MEDICAL REPORT: SUSPECTED CHILD PHYSICAL ABUSE AND NEGLECT EXAMINATION OES 900 State of California Governor s Office of Emergency Services MEDICAL REPORT: SUSPECTED CHILD PHYSICAL ABUSE AND NEGLECT EXAMINATION OES 900 For more information or assistance in completing the OES 900,

More information

New Perspective Counseling Services Child/Teen Intake Form

New Perspective Counseling Services Child/Teen Intake Form Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.

More information

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************

More information

2016 MONTANA YOUTH RANGE CAMP

2016 MONTANA YOUTH RANGE CAMP 2016 MONTANA YOUTH RANGE CAMP Hosted by the Cascade Conservation District Sponsored by the Department of Natural Resources and Conservation http://dnrc.mt.gov/cardd/camps/rangecamp/default.asp Camp Rules

More information

Rahab s Rope Application Instructions:

Rahab s Rope Application Instructions: We are so excited to have you join our work in India. The first step in the process for any volunteer is to fill out the following application in full. Rahab s Rope Application Instructions: Complete the

More information

Excel Photography Program: Summer 2015 for HOPE Village youth currently in 6 th 8 th grades @ Focus: HOPE

Excel Photography Program: Summer 2015 for HOPE Village youth currently in 6 th 8 th grades @ Focus: HOPE Excel Photography Program: Summer 2015 for HOPE Village youth currently in 6 th 8 th grades @ Focus: HOPE Are you interested in participating in exciting photo shoot field trips and a public art installation

More information

COMMUNITY FOR NEW DIRECTION PARTICIPANT REGISTRATION FORM

COMMUNITY FOR NEW DIRECTION PARTICIPANT REGISTRATION FORM COMMUNITY FOR NEW DIRECTION PARTICIPANT REGISTRATION FORM Child s Name (Last) (First) (Middle Init.) Address Apt. # Zip Code Home Telephone Message Telephone Birth Age *Gender: Male Female *Race (please

More information

Application Form. Global Green MBA

Application Form. Global Green MBA Faculty of Management The International School Application Form Global Green MBA Instructions All of the following materials must be submitted before your application will be processed: Application Form

More information

Project Aerospace ACE Academy Application

Project Aerospace ACE Academy Application Project Aerospace ACE Academy Application Location: (s): The OBAP Aviation Career Education (ACE) Academy is designed to provide a more in-depth look at the aviation industry for students who truly want

More information

camp rules/behavior agreement

camp rules/behavior agreement camp rules/behavior agreement Lake Metroparks camps use assertive discipline techniques that are used to strengthen good behavior by the use of positive reinforcement such as verbal praise, smiles, awards,

More information

Address: Street City State Zip Code Home Phone: E-mail Address:

Address: Street City State Zip Code Home Phone: E-mail Address: SANDWICH CUSD #430 REGISTRATION FORM SCHOOL YEAR 2013-2014 SELECT AN ATTENDANCE CENTER LG Haskin Prairie View WW Woodbury HE Dummer Middle School High School 1. NAME: 5. SEX: Male Female Last Name First

More information

Personal Training Health Screening Questionnaire

Personal Training Health Screening Questionnaire Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:

More information

West Virginia University 2015 Forensic Science Summer Camp

West Virginia University 2015 Forensic Science Summer Camp Thank you for registering for the! This packet contains the following forms that must be completed and returned before the student will be allowed to attend camp: Participant Information Form Event Participant

More information

SOUTHWEST OHIO INLINE HOCKEY PLAYER DOCUMENTATION COVERSHEET

SOUTHWEST OHIO INLINE HOCKEY PLAYER DOCUMENTATION COVERSHEET SOUTHWEST OHIO INLINE HOCKEY PLAYER DOCUMENTATION COVERSHEET School / Team: Name: Address: City, State, Zip: Home Phone: Cell Phone: Email: (please circle your responses) Do you attend the above named

More information

Bartow County C.E.R.T.

Bartow County C.E.R.T. Dear Applicant, I would like to take this opportunity to thank you for your interest in the Community Emergency Response Team. The CERT Program is presented by the Bartow County Emergency Management Agency

More information

Player Name: Returning New Player First Middle Last. Ethnicity: African American Asian Caucasian Hispanic Multi-Racial Native American Other

Player Name: Returning New Player First Middle Last. Ethnicity: African American Asian Caucasian Hispanic Multi-Racial Native American Other RBI PLAYER REGISTRATION FORM Player Name: Returning New Player First Middle Last Gender: Male Female Birthday: / / Age: Ethnicity: African American Asian Caucasian Hispanic Multi-Racial Native American

More information

Excel Photography Program Fall 2015

Excel Photography Program Fall 2015 Excel Photography Program Fall 2015 The Excel Photography Program offers a range of opportunities for 6 th 8 th grade students who either live or attend school in the HOPE Village to develop their knowledge

More information

Lighthouse Christian Academy

Lighthouse Christian Academy Lighthouse Christian Academy APPLICATION - FORM 1 of 9 Term 20-20 Date Office Use Only Interviewed By: Status: STUDENT INFORMATION (Please print or type) Name (Last) (First) (Middle) Address (Street) (City)

More information

Please email: tchin@sbnature2.org for more details.

Please email: tchin@sbnature2.org for more details. Medication Protocol: All medications (both over-the-counter and prescribed) must be cleared by the camper s guardian (additionally all prescribed meds must be cleared by a Physician) by filling out the

More information

Santa Monica College Administrative Regulation - Students Activities and Student Conduct

Santa Monica College Administrative Regulation - Students Activities and Student Conduct Santa Monica College Administrative Regulation - Students Activities and Student Conduct (AR5319-091481) Extracurricular Trips Arrangements for trips by clubs and other non-athletic extracurricular activity

More information

California Polytechnic State University, Pomona Vietnamese Student Association. Family. Honor. Tradition.

California Polytechnic State University, Pomona Vietnamese Student Association. Family. Honor. Tradition. California Polytechnic State University, Pomona Vietnamese Student Association Family. Honor. Tradition. ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM Name of Activity or Event: CAL POLY POMONA VSA WINTER

More information

FOR OFFICE ONLY. Occupation: Company/Organisation: Work Phone Number: Home Phone Number: Fax Number:. E-MAIL ADDRESS:...

FOR OFFICE ONLY. Occupation: Company/Organisation: Work Phone Number: Home Phone Number: Fax Number:. E-MAIL ADDRESS:... P.O. Box 1242, Gweru E-mail:admin@mcc.ac.zw Zimbabwe admissions@mcc.ac.zw Telephone: 263-054-224930, 223153, 220788, 220905 Fax: 263-054-226081 APPLICATION FORM SIXTH FORM (L6 & U6) Rec. No.:.. App. Returned:

More information

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900 PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip

More information

UNIVERSITY OF HOUSTON STUDY ABROAD PROGRAM ACTIVITIES PARTICIPANT S RELEASE AND WAIVER OF LIABILITY AGREEMENT (Form A1) I. RELEASE

UNIVERSITY OF HOUSTON STUDY ABROAD PROGRAM ACTIVITIES PARTICIPANT S RELEASE AND WAIVER OF LIABILITY AGREEMENT (Form A1) I. RELEASE UNIVERSITY OF HOUSTON STUDY ABROAD PROGRAM ACTIVITIES PARTICIPANT S RELEASE AND WAIVER OF LIABILITY AGREEMENT (Form A1) This Release and Waiver of Liability Agreement is entered into by all Participants

More information

Aquaculture and Conservation Biology Summer Camp 2014 Registration Form

Aquaculture and Conservation Biology Summer Camp 2014 Registration Form All forms and payment are due no later than June 1, 2014 Participant s Name (First, Last) Age Grade in Fall 2014 Sex Street Address Apt.# City, State Zip Code Guardian Name Cell Phone Number E-Mail Address

More information

Building Bridges through Music Participant Registration Form

Building Bridges through Music Participant Registration Form SOCIAL DIVERSITY FOR CHILDREN FOUNDATION EMPOWERING YOUTH TO EMPOWER CHILDREN WITH DISABILITIES Building Bridges through Music Participant Registration Form Administration Use Only Registration #: Date

More information

Standard Field Trip Please check one Non-Standard Field Trip

Standard Field Trip Please check one Non-Standard Field Trip Risk Management 520-2164 COLORADO SPRINGS SCHOOL DISTRICT 11 FIELD TRIP APPROVAL FORM Standard Field Trip Please check one n-standard Field Trip Submitted by: Contact Phone # School: Today s date I. Activity:

More information

James A. Purvis, Ph.D. Psychotherapy Services Agreement

James A. Purvis, Ph.D. Psychotherapy Services Agreement James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist

More information

Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 1 of 5. Respite Program:

Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 1 of 5. Respite Program: Jacob s Ladder Pediatric Rehab Center: Respite Program Intake Packet Page 1 of 5 Respite Program: Child s Name #1 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Child s Name #2 Age Birth

More information

FOOTBALL CAMPS OF AMERICA, LLC CONSENT FORM

FOOTBALL CAMPS OF AMERICA, LLC CONSENT FORM FOOTBALL CAMPS OF AMERICA, LLC CONSENT FORM NOTICE: ALL ATHLETES WILL BE REQUIRED TO HAVE A SIGNED CONSENT FORM BEFORE TAKING THE FIELD. Football Camps of America, LLC. Parental Release Physical Form Waiver

More information

La Salle College High School Junior Summer Service Immersion Application. Instructions

La Salle College High School Junior Summer Service Immersion Application. Instructions La Salle College High School 2016 Junior Summer Service Immersion Application Instructions *** Due in Campus Ministry no later than Wednesday, November 18, 2015 *** Thank you for your interest in La Salle

More information

DRUG, NARCOTIC, AND ALCOHOL POLICY 6360

DRUG, NARCOTIC, AND ALCOHOL POLICY 6360 POTTSTOWN SCHOOL DISTRICT DRUG, NARCOTIC, AND ALCOHOL POLICY 6360 6360.1 Through the use of an up-to-date curriculum, classroom activities, community support and resources, a strong and consistent administrative

More information

2014 High School Police Academy Application Packet. Session 1: July 7 th 11 th Session 2: August 11 th 15 th

2014 High School Police Academy Application Packet. Session 1: July 7 th 11 th Session 2: August 11 th 15 th 2014 Application Packet Session 1: July 7 th 11 th Session 2: August 11 th 15 th The Charlotte-Mecklenburg Police Department is offering high school students in Mecklenburg County the opportunity to experience

More information

juilliard.edu/summerjazz

juilliard.edu/summerjazz Juilliard JAZZ Summer 2013 Camp in Atlanta,GA June 17-21, 2013 One-week program for dedicated and disciplined students ages 12-18, who are passionate about jazz music For details see Juilliard s Web site:

More information

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments

More information

Brentwood School District

Brentwood School District Brentwood School District Dear Families, It is a pleasure to welcome you to kindergarten and to the Brentwood School District! Our commitment is to grow capable learners and inspire lifetime leaders. We

More information

I request air transportation. TO CAMP RETURN FLIGHT HOME. I request ground transportation TO CAMP FROM CAMP TO HOME

I request air transportation. TO CAMP RETURN FLIGHT HOME. I request ground transportation TO CAMP FROM CAMP TO HOME CAMPER APPLICATION 2015 Camp Director with Responsibility for Campers Lisa Perez 1401 S. Harbor Blvd, #11C La Habra, CA 90631 Email: californialionscamp@gmail.com Name of Child Camp Pacifica is a camping

More information

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078 Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd

More information

IMPORTANT: THIS IS A LEGAL DOCUMENT, PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING

IMPORTANT: THIS IS A LEGAL DOCUMENT, PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING IMPORTANT: THIS IS A LEGAL DOCUMENT, PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING. ASSUMPTION OF RISK, WAIVER OF LIABILITY AND INDEMNIFICATION AGREEMENT This agreement (the Agreement ) must

More information

THOMPSON SCHOOL DISTRICT CHECKLIST FOR ATHLETIC PARTICIPATION

THOMPSON SCHOOL DISTRICT CHECKLIST FOR ATHLETIC PARTICIPATION THOMPSON SCHOOL DISTRICT CHECKLIST FOR ATHLETIC PARTICIPATION Check As Completed All forms returned to the school office. Revised 6/12/15 Part A PARENT PERMIT FOR ATHLETIC PARTICIPATION AND INSURANCE COVERAGE

More information

Please put above in a plastic Ziploc bag with your child s name on it.

Please put above in a plastic Ziploc bag with your child s name on it. Dear Parent(s), You have noted your child has medications related to an allergic reaction. The Stamford Museum & Nature Center s requirements for noted medications are as follows: Epi-pen requirements

More information

Annual BSA Health and Medical Record Part A GENERAL INFORMATION

Annual BSA Health and Medical Record Part A GENERAL INFORMATION Full name: DOB: Allergies: Emergency contact.: Annual BSA Health and Medical Record Part A GENERAL INFORMATION High-adventure base participants: Expedition/crew.: or staff position: Name Date of birth

More information

Administration of Oral Prescription Medication Directive

Administration of Oral Prescription Medication Directive Administration of Oral Prescription Medication Directive Directive for Policy 4.2 Medical/Health Supports Projected Review Date: Nov. 2018 RATIONALE: Hamilton-Wentworth District School Board is committed

More information

Thank you for your interest in the Bet Elazraki Summer Program 2015.

Thank you for your interest in the Bet Elazraki Summer Program 2015. Dear Applicant, Thank you for your interest in the Bet Elazraki Summer Program 2015. About Bet Elazraki: Bet Elazraki Children s Home is home to 241 children from birth to 18 years old. The children are

More information

Personal History Statement Application for Law Enforcement Explorer

Personal History Statement Application for Law Enforcement Explorer Name: Date Applied: Personal History Statement Application for Law Enforcement Explorer The Plano Police Department Explorer Post 911 909 14 th Street Plano, Texas 75086-0358 Instructions Read these instructions

More information

Client Name First Last. Address City State Zip. Home Number Mobile Number. Work Number Email. Name First Last. Address City State Zip

Client Name First Last. Address City State Zip. Home Number Mobile Number. Work Number Email. Name First Last. Address City State Zip CLIENT INFORMATION FORM For Office Use Only Therapist _ CPT Diag Code Fee Start Client DOB _ Client Name First Last Address City State Zip Home Number Mobile Number Work Number Email Parent/Guardian Information:

More information