Paddle For DBS Marina Regatta 2015
|
|
|
- Dale Manning
- 8 years ago
- Views:
Transcription
1 Paddle For DBS Marina Regatta 2015 FRIENDSHIP RELAY 30 May 2015 Please complete pages 1 to 3 if you are registering for yourself only. Please continue to complete the rest of the pages if you are registering for your teammates as well. You may register up to 3 people in your team, and we would allocate each team at least one participant from our selected Voluntary Welfare Organisations (VWOs). We will do our best to keep you in one team if you register together but we may have to split you up in the event some teams need 1-2 more people to form a team of 4. Kindly submit the forms to paddleforgood@societystaples.com.sg. Thank you! Please indicate your preferred slots. Slots will be allocated on a first come first serve basis. 1.45PM PM 3.25PM PM 4.45PM PM *denotes mandatory fields (i) Individual's Particulars (Participant 1) *NRIC / FIN No.: *DATE OF BIRTH (DD/MM/YY): *GENDER: M / F *NATIONALITY: *RESIDENTIAL ADDRESS: *POSTAL CODE: * ADDRESS: Paddle For DBS Marina Regatta 2015 Page 1 of 9
2 (ii) Next-of-Kin Emergency Contact Details *RELATIONSHIP WITH INDIVIDUAL: (H/P) (H) (O) (iii) Medical Declaration 1. Have you ever experienced any of the following: (a) Chest pain, high blood pressure, heart problems such as heart murmur,extra heart beat or other heart abnormality (b) Asthma, bronchitis, tuberculosis, sinusitis and/or other lung problems (c) Fits, epilepsy, fainting attacks, migraine, severe head injury (d) Severe eye problems/poor vision (e) Ear problems/deafness (f) Nervous illness (g) Diabetes (h) Bone or joint injury (i) A carrier status for any infectious disease (j) Medical treatment within last two years (k) Are you pregnant? 2. Do you require: (a) Routine medication (b) Special diet 3. Do you have: YES NO (a) Any disability (b) Any other medical information to note, (ie.food, drug allergy) YES YES NO NO Paddle For DBS Marina Regatta 2015 Page 2 of 9
3 (iv) Indemnity I consent to participate in the Paddle For DBS Marina Regatta I agree to hold Society Staples Pte. Ltd., DBS Bank Ltd, and its co-organizers, their appointed staff or officials free of liability whatsoever for loss of life or injury to person or loss / damage to property of goods whatsoever occasioned during the event. I will abide by the rules and regulations of Paddle For Good 2015 with full knowledge of the consequences that may arise from my participation in the event. I do hereby, for myself, my executors, administrators and assigns, covenant with the organizers and the sponsors to release them from any claim I may have against them in the event of any injury, fatal or otherwise, that I may suffer as a result of my participation in Paddle For Good ) I declare that all the facts stated in this form and the accompanying information is true and correct to the best of my knowledge and that I have not withheld/distorted any material facts. 2) Personal Data Policy: By submitting this form and the subsequent related articles, pictures and/or videos to Society Staples, the participant hereby gives consent to Society Staple s collection, use and disclosure of the participant s personal data for the purpose of collection, use and disclosure for Paddle For Good and/or such other related initiatives as Society Staples may in its determine. PARTICIPANT FULL NAME AS IN NRIC SIGNATURE & DATE (iv) Indemnity (For Participants Below 21 Years Old On 01 January 2015) I, (Name of Parent / Guardian), (NRIC No), (Relationship) of (Participant Name), whose particulars are as written above, validate that I fully understand and appreciate the effect of the above Declaration Clause and hereby agree to allow my ward / child to participate in Paddle For DBS Marina Regatta 2015 and shall not hold the Society Staples Pte. Ltd., DBS Bank Ltd, and its co-organizers, their appointed staff or officials responsible for any mishap, injury, or loss of life whatsoever that may occur in the course of, or as a result of his/her participation in the event. NAME OF PARENT / GUARDIAN AS IN NRIC SIGNATURE OF PARENT / GUARDIAN Paddle For DBS Marina Regatta 2015 Page 3 of 9
4 Paddle For DBS Marina Regatta 2015 Please indicate your preferred slots. Slots will be allocated on a first come first serve basis. 1.45PM PM 3.25PM PM 4.45PM PM *denotes mandatory fields (i) Individual's Particulars (Participant 2) FRIENDSHIP RELAY 30 May 2015 *NRIC / FIN No.: *DATE OF BIRTH (DD/MM/YY): *GENDER: M / F *NATIONALITY: *RESIDENTIAL ADDRESS: *POSTAL CODE: * ADDRESS: (ii) Next-of-Kin Emergency Contact Details *RELATIONSHIP WITH INDIVIDUAL: (H/P) (H) (O) Paddle For DBS Marina Regatta 2015 Page 4 of 9
5 (iii) Medical Declaration 1. Have you ever experienced any of the following: YES NO (a) Chest pain, high blood pressure, heart problems such as heart murmur,extra heart beat or other heart abnormality (b) Asthma, bronchitis, tuberculosis, sinusitis and/or other lung problems (c) Fits, epilepsy, fainting attacks, migraine, severe head injury (d) Severe eye problems/poor vision (e) Ear problems/deafness (f) Nervous illness (g) Diabetes (h) Bone or joint injury (i) A carrier status for any infectious disease (j) Medical treatment within last two years (k) Are you pregnant? 2. Do you require: YES NO (a) Routine medication (b) Special diet 3. Do you have: YES NO (a) Any disability (b) Any other medical information to note, (ie.food, drug allergy) Paddle For DBS Marina Regatta 2015 Page 5 of 9
6 (iv) Indemnity I consent to participate in the Paddle For DBS Marina Regatta I agree to hold Society Staples Pte. Ltd., DBS Bank Ltd, and its co-organizers, their appointed staff or officials free of liability whatsoever for loss of life or injury to person or loss / damage to property of goods whatsoever occasioned during the event. I will abide by the rules and regulations of Paddle For Good 2015 with full knowledge of the consequences that may arise from my participation in the event. I do hereby, for myself, my executors, administrators and assigns, covenant with the organizers and the sponsors to release them from any claim I may have against them in the event of any injury, fatal or otherwise, that I may suffer as a result of my participation in Paddle For Good ) I declare that all the facts stated in this form and the accompanying information is true and correct to the best of my knowledge and that I have not withheld/distorted any material facts. 2) Personal Data Policy: By submitting this form and the subsequent related articles, pictures and/or videos to Society Staples, the participant hereby gives consent to Society Staple s collection, use and disclosure of the participant s personal data for the purpose of collection, use and disclosure for Paddle For Good and/or such other related initiatives as Society Staples may in its determine. PARTICIPANT FULL NAME AS IN NRIC SIGNATURE & DATE (iv) Indemnity (For Participants Below 21 Years Old On 01 January 2015) I, (Name of Parent / Guardian), (NRIC No), (Relationship) of (Participant Name), whose particulars are as written above, validate that I fully understand and appreciate the effect of the above Declaration Clause and hereby agree to allow my ward / child to participate in Paddle For DBS Marina Regatta 2015 and shall not hold the Society Staples Pte. Ltd., DBS Bank Ltd, and its co-organizers, their appointed staff or officials responsible for any mishap, injury, or loss of life whatsoever that may occur in the course of, or as a result of his/her participation in the event. NAME OF PARENT / GUARDIAN AS IN NRIC SIGNATURE OF PARENT / GUARDIAN Paddle For DBS Marina Regatta 2015 Page 6 of 9
7 Paddle For DBS Marina Regatta 2015 Please indicate your preferred slots. Slots will be allocated on a first come first serve basis. 1.45PM PM 3.25PM PM 4.45PM PM *denotes mandatory fields (i) Individual's Particulars (Participant 3) FRIENDSHIP RELAY 30 May 2015 *NRIC / FIN No.: *DATE OF BIRTH (DD/MM/YY): *GENDER: M / F *NATIONALITY: *RESIDENTIAL ADDRESS: *POSTAL CODE: * ADDRESS: (ii) Next-of-Kin Emergency Contact Details *RELATIONSHIP WITH INDIVIDUAL: (H/P) (H) (O) Paddle For DBS Marina Regatta 2015 Page 7 of 9
8 (iii) Medical Declaration 1. Have you ever experienced any of the following: YES NO (a) Chest pain, high blood pressure, heart problems such as heart murmur,extra heart beat or other heart abnormality (b) Asthma, bronchitis, tuberculosis, sinusitis and/or other lung problems (c) Fits, epilepsy, fainting attacks, migraine, severe head injury (d) Severe eye problems/poor vision (e) Ear problems/deafness (f) Nervous illness (g) Diabetes (h) Bone or joint injury (i) A carrier status for any infectious disease (j) Medical treatment within last two years (k) Are you pregnant? 2. Do you require: YES NO (a) Routine medication (b) Special diet 3. Do you have: YES NO (a) Any disability (b) Any other medical information to note, (ie.food, drug allergy) Paddle For DBS Marina Regatta 2015 Page 8 of 9
9 (iv) Indemnity I consent to participate in the Paddle For DBS Marina Regatta I agree to hold Society Staples Pte. Ltd., DBS Bank Ltd, and its co-organizers, their appointed staff or officials free of liability whatsoever for loss of life or injury to person or loss / damage to property of goods whatsoever occasioned during the event. I will abide by the rules and regulations of Paddle For Good 2015 with full knowledge of the consequences that may arise from my participation in the event. I do hereby, for myself, my executors, administrators and assigns, covenant with the organizers and the sponsors to release them from any claim I may have against them in the event of any injury, fatal or otherwise, that I may suffer as a result of my participation in Paddle For Good ) I declare that all the facts stated in this form and the accompanying information is true and correct to the best of my knowledge and that I have not withheld/distorted any material facts. 2) Personal Data Policy: By submitting this form and the subsequent related articles, pictures and/or videos to Society Staples, the participant hereby gives consent to Society Staple s collection, use and disclosure of the participant s personal data for the purpose of collection, use and disclosure for Paddle For Good and/or such other related initiatives as Society Staples may in its determine. PARTICIPANT FULL NAME AS IN NRIC SIGNATURE & DATE (iv) Indemnity (For Participants Below 21 Years Old On 01 January 2015) I, (Name of Parent / Guardian), (NRIC No), (Relationship) of (Participant Name), whose particulars are as written above, validate that I fully understand and appreciate the effect of the above Declaration Clause and hereby agree to allow my ward / child to participate in Paddle For DBS Marina Regatta 2015 and shall not hold the Society Staples Pte. Ltd., DBS Bank Ltd, and its co-organizers, their appointed staff or officials responsible for any mishap, injury, or loss of life whatsoever that may occur in the course of, or as a result of his/her participation in the event. NAME OF PARENT / GUARDIAN AS IN NRIC SIGNATURE OF PARENT / GUARDIAN Paddle For DBS Marina Regatta 2015 Page 9 of 9
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
Livingstone 4X4 Challenge Registration Form
Livingstone 4X4 Challenge Registration Form About You Give forename and surname as they appear on your passport please Title: Surname: Forename: Known As: Home Phone: Work Phone: Mobile Phone: Post Code:
Insurance Protection for Contract Courier Drivers
Masefield Holdings Pty Ltd ACN 009 128 394 ABN 70 970 795 411 As Trustee for the GRAHAM KNIGHT UNIT TRUST Trading as Graham S Knight & Associates Insurance Brokers PO Box 160 BELMONT WA 6984 Telephone:
REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:
Jaworski Physical Therapy, Inc. Private Health Insurance. Worker s Compensation (complete the following)
Jaworski Physical Therapy, Inc. Patient Name: Date: Private Health Insurance Name of Private Health Insurance: ID#: Group#: Cardholder Name: Cardholder Date of Birth: Relationship to Patient: Phone: Address
Nearest Relative Information (Not in same household)
Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction
MASTER DEGREE PROGRAMME IN USM
The CPS-USM SCHOLARSHIP PROGRAMME 2012/2013 Recent Photograph (3 Photos) MASTER DEGREE PROGRAMME IN USM APPLICATION FOR ADMISSION (in duplicate) Area of Specialization: (2 sets of applications need to
Sun Life and Health Insurance Company (U.S.)
Sun Life and Health Insurance Company (U.S.) One Sun Life Executive Park, Wellesley Hills, MA 02481] [800-247-6875 Evidence of Insurability Cover Page Employer Instructions Complete this cover page and
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:
REGISTRATION & MEDICAL FORM
REGISTRATION & MEDICAL FORM NAME ADDRESS CITY PROV POSTAL TELEPHONE E-MAIL CLUB BIRTH DATE DD/ MM / YYYY AGE (on Dec. 31, 2011) GENDER: M F MB MEDICAL # For Office Use Only: Plate number: Category: Amount
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
Family Name (surname) : Date of birth : Day Month Year First Name : Nationality ( citizenship ) : Telephone : Mobile Phone Number: Address :
Please affix passport photograph APPLICATION FORM SHORT TERM COURSE IN MALAYSIA UNDER THE MALAYSIAN TECHNICAL COOPERATION PROGRAMME ( MTCP ) Please type or write clearly in capital letters. Do not leave
Summer Youth Musical Theater Workshop Registration Form
2015 Summer Youth Musical Theater Workshop Registration Form PLEASE READ THIS FORM CAREFULLY Please complete the entire registration form and mail it along with your enrollment fee to: Musicals at Richter,
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required
GROUP INSURANCE EVIDENCE OF INSURABILITY FORM. SECTION 1: EMPLOYER INFORMATION (to be completed by authorized Plan Administrator):
GROUP INSURANCE EVIDENCE OF INSURABILITY FORM RBC Life Insurance Company 6880 Financial Drive, Tower 1, Eighth Floor Mississauga, Ontario L5N 7Y5 Please answer all applicable questions; all subsequent
FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Parental Consent form (for participants under 18 years)
YOUTH Course / Event Application Form Course / Event Type: Course Date: Applicant s Name: Address: Postcode: Date of birth: Is applicant a Club member - Yes / No Name of Parent /Guardian (if under 18)
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
Please find attached an application form, please read the following information before completing the form.
Page: 1 of 12 STEAM MILL BUSINESS CENTRE STEAM MILL STREET CHESTER CH3 5AN TEL: 01244 354700 FAX: 01244 354720 E-MAIL: info@anchorgroup.eu WEB SITE: http://www.anchorgroup.eu Dear Candidate, Re: Job Application
Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-
HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
RECRUITMENT ACTIVITIES PARENT / GUARDIAN CONSENT FORM
RECRUITMENT ACTIVITIES PARENT / GUARDIAN CONSENT FORM PLEASE NOTE: This is the consent form required for candidates under the age of 18 to take part in activities related to the recruitment process (including
Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST
Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST Page 2 (Physical Examination Form): Page two of this packet is the ONLY
REHAB XCEL, LLC. NEW PATIENT INFORMATION
REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
Please complete the Consent Form and the Respirator Certification Questionnaire.
The Occupational Safety and Health Administration (OSHA) Respiratory Protection Standard requires an employee to complete a questionnaire if the employee is required to wear a respirator. You have been
J UNE 15 - AUGUST 7 GRADES (going into) HEADSTART - 7th grade
J UNE 15 - AUGUST 7 GRADES (going into) HEADSTART - 7th grade Our day camp offers structured activities from 8:00 a.m. to 5:00 p.m., 5 days a week for an eight-week program, all at one low price. Children
How To Get A Job Insurance Plan For A Chiropractic Patient
Cole Family Chiropractic 68 rth High Street, Ste E-106, New Albany, OH 43054 (614) 855-5454 (p) ~ (614) 283-5400 (f) WORKERS COMPENSATION HISTORY Patient Name: Employers Name: Telephone Number: Address:
Indemnity Form. Phone Numbers : (Home) (Office) (Mobile) Please answer the following questions (*Please circle your answer):
Indemnity Form Full name : NRIC No. / Passport No. : Phone Numbers : (Home) (Office) (Mobile) Address : Date of Birth/ Age (as of 1/1/14) : Occupation : Marital status : Hobbies : Tell us something interesting
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
Helen Rollason Cancer Charity Sahara Challenge 10 th 17 th October 2015
Helen Rollason Cancer Charity Sahara Challenge 10 th 17 th October 2015 Please return this completed form, along with your cheque (if applicable) and passport copy to: The Different Travel Company, 4 Downs
INSTRUCTIONS FOR COMPLETING REGISTRATION. 2. Fill out the forms completely with necessary information and signatures:
INSTRUCTIONS FOR COMPLETING REGISTRATION 1. Print out the Waiver of Liability, Medical Release Form and Participant Information Sheet attached to this document 2. Fill out the forms completely with necessary
Galerie Dental Care. Patient Information. Emergency Contact Relationship: Phone:
Galerie Dental Care Patient Information Date: Patient Name: Last First Middle Initial (Preferred Name) Gender: Birth Date: Marital/Family Status Address: Street Apartment # City Province Postal Code Phone
How To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
KEY PERSON INSURANCE (Accident & Sickness) PROPOSAL FORM
KEY PERSON INSURANCE (Accident & Sickness) PROPOSAL FORM E.U. DISCLOSURE CLAUSE (UK) tice to the Proposer/Insured The Parties are free to choose the law applicable to this insurance Contract. Unless specifically
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please
Term Life Insurance Plan
Term Life Insurance Plan Your association is pleased to endorse Term Life Insurance available to you and your spouse. You can choose the coverage amount to fit your needs. Term Life is an affordable way
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
PERSONAL TRAINING CLIENT INFORMATION PACKAGE
PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means adopting a lifestyle that strengthens the body and
INTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE
INTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE FOR U.S. Dollar Term Life Insurance for use when there is an international insurable interest involved. USES Employees of Foreign National Firms International
PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form
Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate. A completed Health Insurance
Brunei-U.S. English Language Enrichment Project for ASEAN: 11-Week English Language Programme
2014 Application Form Please complete all parts of this application form in PRINT Brunei-U.S. English Language Enrichment Project for ASEAN: 11-Week English Language Programme PLEASE INDICATE THE COURSE
HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
CRISIS COVER CLAIM FORM (DEAFNESS/ PARTIAL LOSS OF HEARING OR CAVERNOUS SINUS THROMBOSIS SURGERY/ COCHLEAR IMPLANT SURGERY) SECTION
Reg. No 199002477Z CRISIS COVER CLAIM FORM (DEAFNESS/ PARTIAL LOSS OF HEARING OR CAVERNOUS SINUS THROMBOSIS SURGERY/ COCHLEAR IMPLANT SURGERY) SECTION 1 This section is to be completed by the Life Assured
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. **************************************
PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address:
NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049 ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE:
Physical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
(All Answers to be filled in legibly. Answers must be given in words. Stroke of the pen or dots or dashes will not be accepted as replies.
F.No. 300 (Rev.98) Proposal No.: Branch (Established by the Life Insurance Corporation Act, 1956) PROPOSAL FOR INSURANCE ON OWN LIFE (Not to be used for Insurance on the Lives of minors) Agents Code Number
AIA International Limited Personal Life & Medical Insurance Program For Members of Hong Kong Institute of Certified Public Accountants Application
AIA International Limited Personal Life & Medical Insurance Program For Members of Hong Kong Institute of Certified Public Accountants Application Form Personal Details of Insured Person Member Accountant
BUPA Health Insurance (Thailand) Ltd. 104/9 Unit M02-03 The Avenue Chaengwattana Moo 1 Chaengwattana Tungsonghong Laksi Bangkok 10210
BUPA Health Insurance (Thailand) Ltd 104/9 Unit M02-03 The Avenue Chaengwattana Moo 1 Chaengwattana Tungsonghong Laksi Bangkok 10210 Tel. 02 573 8700 Fax 02 573 8711 Application Form Suggestion for filling
IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
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
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
EZ REHAB SOLUTIONS: Patient Intake Information
EZ REHAB SOLUTIONS: Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
Illinois Standard Health Employee Application for Small Employers
INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period For assistance in completing this application, please contact your employer or insurance agent. For information about
Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
Patient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:
DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: - - Email: Address: City: State: Zip: Sex: M F Birthdate:
Patient Registration Please Print Patient Name Last First Middle
Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact
Personal Accident & Illness Application Form
Personal Accident & Illness Application Form Personal Accident & Illness Application Form Important Notice to the Proposer for completion of this proposal form 1. Disclosure Any 'material fact' must be
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
AVIVA LTD 4 Shenton Way #01-01, SGX Centre 2, Singapore 068807 Telephone: 6827 7988 Fax: 6827 7900 Company Reg. No. 196900499K CRITICAL ILLNESS &/OR
CRITICAL ILLNESS &/OR MALE/FEMALE/CHILD ILLNESS CLAIM - CLAIMANT S STATEMENT Dear Claimant We re sorry to receive notice of the Life Assured s condition. To enable us to process your claim, please follow
WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance INSTRUCTIONS - Please print all answers If required, retain a photocopy for your files. 1a) Plan contract number(s)
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?
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
Pittsfield Family YMCA: Personal Training Services
Pittsfield Family YMCA: Personal Training Services I would like to purchase the following Client s Name personal training package with personal trainer : Trainer s Name 1 Session, $40 2 Sessions, $80 5
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Work Injury Information Continued
Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
Greetings from Oklahoma Wesleyan University Student Health Services! STUDENT HEALTH OFFICE AND MEDICAL ATTENTION MEDICAL FORMS PHYSICAL EXAMS
Return all medical forms to: Student Health Department Oklahoma Wesleyan University 2201 Silver Lake Road Bartlesville, OK 74006 Greetings from Oklahoma Wesleyan University Student Health Services! My
This policy applies to the whole school so includes the EYFS setting.
POLICY ON ADMINISTRATION OF MEDICINES IN SCHOOL The policy on the administration of medicines at APS is posted on the School s web site and is available to all parents and prospective parents. A printed
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM
ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM Important te: Please note that, under the policy terms and condition, the policy may be void if any information provided in this claim form are made knowingly
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)
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different
North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
1 5 0 K E N N E D Y D R I V E S O U T H B U R L I N G T O N, V E R M O N T 0 5 4 0 3 8 0 2 4 4 8 9 3 7 0 8 0 2 4 4 8 1 4 1 4 (F)
Worker s Compensation Intake Form : Name: DOB: Social Security Address: City ST Zip Home Phone: Alternate Phone: Occupation: Employer Name: Employer Contact: Do you see a primary care physician for your
Dental Admission Form
Dental Admission Form PERSONAL HISTORY All of the information which you provide on this form will be held in the strictest confidence. Although some questions may seem unimportant at the time, they may
THE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+
THE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+ Surname: First Name: Date of Birth: NHS Number: / / Mobile Telephone No: Male / Female If you wish to sign up for Vision On-Line services
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
New Patient Registration Form
New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,