2016 Boston Marathon Wediko Team Application Overview

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "2016 Boston Marathon Wediko Team Application Overview"

Transcription

1 2016 Boston Marathon Wediko Team Application Overview Thank you for taking the time to complete this application. Wediko Children s Services believes children s mental health matters and that children do best when all of the adults in their life are working together. On behalf of the children, families, and schools served by Wediko, we thank you for considering making a difference and joining our team. We are looking forward to a successful and exciting marathon training season! Wediko has supported a Boston Marathon team since We believe this opportunity truly enhances the Boston Marathon experience. As a member of Team Wediko you will share great comradery with your fellow team members, benefit from coaching and fundraising support, and enjoy weekly team long runs. All while supporting at risk and under-served children and families. To be considered for selection to the 2016 Wediko Boston Marathon team, please mail, fax, or scan your completed application to the address below. While the team is chosen on a rolling basis, please submit by November 20, All applicants will be notified by December 7, 2015 of their status. Send complete applications to: Kate Regal Wediko Children s Services E. Dedham St. Boston, MA Fax: Important Dates & Milestones! Completed Applications ASAP and no later than November 20, 2015 Notification of Team Assignment Rolling, no later than December 7, 2015 $100 deposit due to reserve your spot! December 11, 2015 (official team members Deadline to withdraw from team and avoid fundraising requirement. only) December 18, 2015 (Noon, EST) $2500 Fundraising Milestone Due February 1, 2016 $5000 Fundraising Milestone Due March 1, 2016 $7500 Fundraising Milestone Due April 1, 2016 Running of the 120 th Boston Marathon!! April 18,

2 Benefits of being a member of the Wediko Marathon Team: Guaranteed race entry for the 120 th Boston Marathon on April 18, 2016 Connect with a team of runners who are committed to training for a marathon and raising money to support Wediko Receive weekly coaching and fundraising support from the Wediko coach who has run Boston 13 times and raised over $160,000 for charity Weekly team training runs (many held on the Boston Marathon course) Fundraising handbook with strategies to assist you in raising money Online fundraising Wediko Marathon Team running singlet, pre-race pasta lunch, and post-marathon gathering The knowledge that the miles you train and the race you run makes a difference for children and families struggling with issues related to mental health and learning challenges. Responsibilities of being a member of the Wediko Marathon Team: $350 race entry fee. (This f.ee is payable to the B.A.A. and is not part of the fundraising commitment. This fee is due in January.) Commit to raise a minimum of $7500 to support Wediko Children s Services by 4/1/16. Be physically able to complete the marathon in under 6 hours. If you are local to Boston, attend Wediko Marathon Team meetings between December 2015 and April Participate in monthly fundraising conference call Wear Wediko Team singlet in 2016 Boston Marathon 2

3 Wediko Boston Marathon Charity Team Application Last Name First Name MI Street Address City State Zip Address Home Phone Cell Phone Work I prefer to be contacted at Home Work Cell Employer Title Does your company have a Matching Gift program? Yes No Gender : M F DOB: / / T-shirt Size: Singlet Size: We would like to know more about you. (Add another page if necessary) Please tell us about: Running Experience: Have you run a marathon before? Yes No How many marathons? Have you run the Boston Marathon before? Yes No How many times?/when? Fastest Marathon time: Have you run a half-marathon before? Yes No How many? Average pace? Fundraising Experience: Have you ever raised significant funds for a program/charity before? Yes No If yes, for which charity and how much money did you raise? Charity Name/Event Year: Amount raised: $ Charity Name/Event Year: Amount raised: $ Charity Name/Event Year: Amount raised: $ 3

4 What will be your fundraising goal for the 2016 Wediko Marathon Team? $ How do you plan to raise these funds? (Please be as detailed as you can be about your plan) Interest in Joining the Wediko Marathon Team: How did you learn about the Wediko Marathon Team? Why are you interested in running for Wediko? What other community organizations are you involved with? 4

5 Wediko Children s Services Terms and Conditions Application Process: Once you have submitted your application, Wediko Children s Services may contact you by phone to discuss your application. Your selection to be a member of the Wediko team will be conditioned on a number of factors, including your completed application and fundraising commitment. Once you accept a position on the team, Wediko will collect $100 deposit to secure your spot. This deposit is part of your fundraising total and counted towards your commitment. It is non-refundable if you cancel your participation. Cancellation Policy: Prior to December 18, 2015 (at noon, EST), you may cancel your participation with the Wediko Boston Marathon team and waive your fundraising requirement. To cancel, you must contact Kate Regal in writing on or before December 18, Your $100 deposit and any donations received by our office are non-refundable. There is no cancellation after December 18, If for any reason you are unable to run the marathon (injury, work commitment, family or other emergency, etc.), you remain responsible for the $7500 fundraising commitment. Again, donations received by our office are not refundable. Fundraising Commitment: When you join the Wediko Boston Marathon team, you commit to a fundraising requirement of $7500. We hope you will be extremely successfully and surpass this minimum! However, should you fall short, your credit card will be charged the difference on each milestone date listed below. We will reimburse your card upon written request once you meet the minimum. After May 15, 2016 we will no longer reimburse you/your card. Fundraising Milestone Due Date $100 December 11, 2015 $2500 February 1, 2016 $5000 March 1, 2016 $7500 April 1, 2016 Qualified Entrants: Wediko welcomes qualified entrants and other official entrants to join the 2016 Wediko Marathon Team. While there is no fundraising minimum, we suggest a goal of $1000. Qualified entrants will be invited to all group runs, pre-marathon pasta luncheon, post-race gathering, and other team events. Qualified entrants are responsible for their own race registration. Matching Gift Policy: Many companies match employees charitable contributions. You can check with your employer to see if your company has this program. We suggest you ask all of your donors if their employers match gifts. As matching gifts are disbursed at different intervals, it is your responsibility to contact the matching company to ensure the check will be issued by April 1,

6 Release Form and Contribution Agreement: In consideration of my joining the Wediko marathon team, I hereby for myself, my heirs, executors and administrators, waive and release any and all rights for claims and damages I may have against Wediko Children s Services, its employees, volunteers, officers, and sponsors for any and all injuries suffered or sustained by me in said event, in the training and planning sessions for said event, or travel to or from any of the proceeding. I further attest and certify that I am physically fit and have sufficiently trained for competition in this event, and a licensed medical doctor has verified my physical condition. I also grant permission for use of my name and or photograph or voice in broadcast, telecast, print, or any other account of this event and agree to waive any compensation for such use. I declare that I have exercised my own judgment in signing this agreement and I further declare that the decision to sign this agreement was voluntary and not based on or influenced by any representation of Wediko Children s Services. In the event of an illness, injury, or medical emergency arising during the event or in the training and planning sessions for said event, I hereby authorize and give my consent to Wediko Children s Services to secure from any accredited hospital, clinic, and/or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any medical services and treatment rendered to me including but not limited to medical transport, medications, treatment, and hospitalization. I am applying to be a member of the 2016 Wediko Marathon Team and hereby accept and agree to the terms and conditions set forth in these Terms and Conditions. Signature: Date: Print Name: Emergency Information: The following person should be contacted in the event of an emergency: Name: Relationship: Telephone Number(s): H: C: W: address: Allergies to Medications: Other relevant medical information: 6

7 Please provide your Credit Card Information: (credit card must have an expiration date later than May 2016 to be valid) *If a spot on the Wediko Marathon team is offered and accepted, a non-refundable deposit of $100 will be charged to hold your spot. This $100 is part of your fundraising commitment. Your card will then only be used if a fundraising milestone is not met (see pg. 1).. Type of card: MasterCard Visa Discover American Express Name on card: Card Number: Expiration date: Security Code: address: Billing Address: Signature of card holder: Thanks again for your interest in running for Wediko and raising much needed funding! We appreciate the time you took to fill out our application. We will confirm receipt of your application within 48 hours. In the meantime, please notify us of any changes to your application, including a change in interest. Good Luck! Submit completed application to: Kate Regal Wediko Children s Services E. Dedham St. Boston, MA Fax:

2016 BOSTON MARATHON APPLICATION TEAM GSEM, a John Hancock Non-Profit Partner 120th Boston Marathon, Monday, April 18, 2016

2016 BOSTON MARATHON APPLICATION TEAM GSEM, a John Hancock Non-Profit Partner 120th Boston Marathon, Monday, April 18, 2016 2016 BOSTON MARATHON APPLICATION TEAM GSEM, a John Hancock Non-Profit Partner 120th Boston Marathon, Monday, April 18, 2016 INSTRUCTIONS FOR INTERESTED RUNNERS All pages of this application must be completed

More information

CYCLE Kids, Inc. Boston Athletic Association 2017 Official Charity Program Application Packet

CYCLE Kids, Inc. Boston Athletic Association 2017 Official Charity Program Application Packet CYCLE Kids, Inc. Boston Athletic Association 2017 Official Charity Program Application Packet To be considered for selection to the 2017 CYCLE Kids Marathon Team, every interested individual (even those

More information

200 Hour Teacher Training Tuition and Application :: Tennessee

200 Hour Teacher Training Tuition and Application :: Tennessee 200 Hour Teacher Training Tuition and Application :: Tennessee $2800 paid in full by January 1 st, 2014; $3100 after Payment options available. Formal registration will be accepted after October 15, 2013.

More information

First Name: Last Name: Home Address/P.O. Box: City: State: Zip:

First Name: Last Name: Home Address/P.O. Box: City: State: Zip: C360: Reg Fee: 1:1: Team In Training Non-Waivered Participant Application First Name: Last Name: Home Address/P.O. Box: City: State: Zip: Primary Phone Number: Secondary Phone Number: Home Work Mobile

More information

Patient History Information

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:

More information

This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015

This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015 STUDENT REGISTRATION FORM Camp Session Dates: June 22, 2015- June 26, 2015 This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015 Last Name: First Name: M.I.: Preferred

More information

Chevron Houston Marathon Run for a Reason Charity Program FAQ

Chevron Houston Marathon Run for a Reason Charity Program FAQ Chevron Houston Marathon Run for a Reason Charity Program Thank you for your interest in our Run for a Reason charity program. Please see below for general information and how to request an application

More information

EVENT AND REGISTRATION INFORMATION

EVENT AND REGISTRATION INFORMATION C360: Reg Fee: 1:1: Team In Training Waivered Participant Application First Name: Last Name: Home Address/P.O. Box: City: State: Zip: Primary Phone Number: Secondary Phone Number: Home Work Mobile Home

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

Aquaculture, Biology, and Conservation Summer Camp 2015 Registration Forms

Aquaculture, Biology, and Conservation Summer Camp 2015 Registration Forms Aquaculture, Biology, and Conservation Summer Camp 2015 Registration Forms All forms and payment are due no later than June 15, 2015 Note: There is a $25 non-refundable registration fee, and no refunds

More information

A GREAT START TO THE DAY

A GREAT START TO THE DAY A GREAT START TO THE DAY GREATER BURLINGTON YMCA Before School Program Essex Elementary WELCOME TO Y BEFORE SCHOOL The Y knows kids. And we understand the needs of working families. Our Before School programs

More information

Welcome TO THE PRACTICE

Welcome TO THE PRACTICE Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers

More information

Membership Application

Membership Application Please type or print clearly Application date Organization name Address City State Zip+4 Primary contact name Telephone Fax Primary contact email Company website address to appear in web listing Business

More information

Delta Sungod Swim Club 2015-16 Season - Registration Form

Delta Sungod Swim Club 2015-16 Season - Registration Form 2015-16 Season - Registration Form Parent s Email Address: All club correspondence goes out via email. Club web login and password emailed upon successful registration. Member Information: (Please complete

More information

Council of Colleges of Acupuncture and Oriental Medicine. Clean Needle Technique Course Application Packet

Council of Colleges of Acupuncture and Oriental Medicine. Clean Needle Technique Course Application Packet Council of Colleges of Acupuncture and Oriental Medicine Clean Needle Technique Course Application Packet Dear CNT Applicant, Thank you for your interest in the Clean Needle Technique (CNT) course, administered

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

EAST TENNESSEE CHILDREN S HOSPITAL

EAST TENNESSEE CHILDREN S HOSPITAL Children s Miracle Network Hospitals Partner Fundraising Policy We are honored you would like to plan a fundraiser for East Tennessee Children s Hospital, your Children s Miracle Network Hospital. Any

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

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone

More information

REGISTRATION FEE REIMBURSEMENT PLAN

REGISTRATION FEE REIMBURSEMENT PLAN REGISTRATION FEE REIMBURSEMENT PLAN The terms and conditions of the Registration Fee Reimbursement Plan (herein called the Plan ) described below apply to the event for which you have registered and that

More information

Preferred Pharmacy: Phone: Fax:

Preferred Pharmacy: Phone: Fax: PATIENT INFORMATION: TODAY S DATE Last Name: Date of Birth: Sex: Male Female First Name: SS#: Middle Initial: Marital Status: Street Address: City: State: Home Phone: Work Phone: Mobile Phone: Email: Contact

More information

Dear Corner Stone Charter Parent:

Dear Corner Stone Charter Parent: Dear Corner Stone Charter Parent: Welcome to Boll Family YMCA s School Age Child Care (SACC) program. We are looking forward to sharing the next 11 months with your child before and after school. Attached

More information

GIRLS SOAR! AVIATION DAY CAMP

GIRLS SOAR! AVIATION DAY CAMP GIRLS SOAR! AVIATION DAY CAMP Saturday, March 19, 2016 9:00am 3:00 pm American Airlines C.R. Smith Museum $25 Member/ $35 Non-Member Registration Take off with us at our 1 st Girls Soar Aviation Day Camp!

More information

Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066

Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066 IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# -- -- MO DAY YEAR CONTACT HOME PHONE: EMAIL: WORK PHONE: Preferred method of communication Email Mail Home Phone

More information

CONTRACT FOR PRIVATE MUSIC INSTRUCTION

CONTRACT FOR PRIVATE MUSIC INSTRUCTION CONTRACT FOR PRIVATE MUSIC INSTRUCTION I. GENERAL CONDITIONS i. Lessons will be offered over the academic year in each of the instruments for which the student is registered. Students will be scheduled

More information

2015 RACE REGISTRATION packet

2015 RACE REGISTRATION packet 2015 RACE REGISTRATION packet First annual Delaware Charity Challenge Saturday, May 2, 2015 Lums Pond State Park Bear, Delaware delawarecharitychallenge.com Saturday, May 2, 2015 Lums Pond State Park 2015

More information

Virginia Aquarium & Marine Science Center 2016 SUMMER DAY CAMPS REGISTRATION FORM. Participant s Name Birth Date Camp Title Camp Date Camp Fee

Virginia Aquarium & Marine Science Center 2016 SUMMER DAY CAMPS REGISTRATION FORM. Participant s Name Birth Date Camp Title Camp Date Camp Fee Virginia Aquarium & Marine Science Center 2016 SUMMER DAY CAMPS REGISTRATION FORM Please bring this completed form to on-site registration on April 6, 2016. Registrations will not be accepted by mail or

More information

WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:

WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel

More information

Culinary Arts Academy Admission Application

Culinary Arts Academy Admission Application Culinary Arts Academy Admission Application Institute for Hospitality & Tourism Education and Research 3000 N.E. 151st Street, KCC 3RD FL North Miami, FL 33181-3000 Please download, complete and save the

More information

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: ( Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.

More information

Your appointment is scheduled for at with Dr. Your arrival time is.

Your appointment is scheduled for at with Dr. Your arrival time is. Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half

More information

SUMMER 2016 TRACK AND FIELD REGISTRATION PACKAGE. Website:

SUMMER 2016 TRACK AND FIELD REGISTRATION PACKAGE. Website: SUMMER 2016 TRACK AND FIELD REGISTRATION PACKAGE Website: www.theheattrackclub.com E-Mail: admin@theheattrackclub.com 770-234-6834 2016 REGISTRATION FORM PLEASE PRINT Athlete s Name: Date of Birth: / /

More information

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code: Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:

More information

Application Summer Study - Pre-College New York Summer Study 2016

Application Summer Study - Pre-College New York Summer Study 2016 Application Summer Study - Pre-College New York Summer Study 2016 First Name Birth Date (Month/Day/Year) Address Last Name Male Female City State Zip/Country code Country Home Tel. E-mail Current School

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

Patient Registration Please Print Patient Name Last First Middle

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

More information

Advanced SPIRIT Association

Advanced SPIRIT Association Advanced SPIRIT Association Registration Packet Ladybug Classic April 5, 2014 Whittemore Center Durham, NH REGISTRATION PACKET CHECKLIST STEP 1: Program Information Please complete all contact information

More information

Nova Medical & Urgent Care Center, Inc Financial Policy

Nova Medical & Urgent Care Center, Inc Financial Policy Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care

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

GATEWAY DISCOVERY CAMP

GATEWAY DISCOVERY CAMP GATEWAY DISCOVERY CAMP SUMMER 2 0 1 6 REGISTRATION FORM Gateway Science Museum will host three sessions of the Gateway Discovery Camp. All sessions run 9am to 3pm and include daily snacks and lunches.

More information

TUITION RATES SCHOOL YEAR 2015-2016

TUITION RATES SCHOOL YEAR 2015-2016 TUITION RATES SCHOOL YEAR 2015-2016 REGISTRATION FEE: $65.00 per child DISCOUNTS: Family discount apply to families with two or more children in the Extended Day program. Full price is paid for the youngest

More information

REGISTRATION & MEDICAL FORM

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

More information

Teacher Application Form

Teacher Application Form Teacher Application Form 210 Commerce Lake Drive Saint Augustine, FL 32095 Phone: (904) 940-9410 Fax: (904) 940-9411 Your interest in Roots and Wings Learning Center is greatly appreciated. Our teachers

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

DUSTIN McDANIEL ATTORNEY GENERAL OFFICE OF THE ATTORNEY GENERAL 323 CENTER STREET, Suite 200 LITTLE ROCK, AR 72201-2610 (501) 682-2007

DUSTIN McDANIEL ATTORNEY GENERAL OFFICE OF THE ATTORNEY GENERAL 323 CENTER STREET, Suite 200 LITTLE ROCK, AR 72201-2610 (501) 682-2007 DUSTIN McDANIEL ATTORNEY GENERAL OFFICE OF THE ATTORNEY GENERAL 323 CENTER STREET, Suite 200 LITTLE ROCK, AR 72201-2610 (501) 682-2007 PAID SOLICITOR APPLICATION FOR REGISTRATION Pursuant to Ark. Code

More information

Medical Mission Pack Program

Medical Mission Pack Program Medical Mission Pack Program For over 125 years, Johnson & Johnson has been committed to improving the health and well-being of mothers and children around the world. With the support of its operating

More information

2015/2016 Tax Season User Guide

2015/2016 Tax Season User Guide 2015/2016 Tax Season User Guide This booklet has been designed to help you understand the process that we follow to complete your tax returns. It will help you to know when to expect information from us

More information

Switch To Volunteer State Bank

Switch To Volunteer State Bank Switch To Volunteer State Bank It s Quick and Easy... Just print the forms below and follow these instructions. Step 1: Complete our New Account Information Form, so we ll have what we need to open your

More information

Registration Form Please Check: Boy Girl Age: Camper s Name: Address: City: State: Zip Code:

Registration Form Please Check: Boy Girl Age: Camper s Name: Address: City: State: Zip Code: Registration Form Please Check: Boy Girl Age: Camper s Name: Address: City: State: Zip Code: Contact Name: Emergency Contact Number: Alt. Emergency Contact Number: E-Mail Address: Alt. Contact Name: Check

More information

Initial. Registration Packet. Summer Academy June 3 rd to August 30 th Z M G. www.zmgtennis.com. HP and TTT Registration Form 1 ZMG Tennis, LLC

Initial. Registration Packet. Summer Academy June 3 rd to August 30 th Z M G. www.zmgtennis.com. HP and TTT Registration Form 1 ZMG Tennis, LLC Registration Packet Summer Academy June 3 rd to August 30 th Z M G www.zmgtennis.com HP and TTT Registration Form 1, LLC Enrolment Process prides its self on offering everything essential in the development

More information

CHALLENGER WORLD TOURS (CWT)

CHALLENGER WORLD TOURS (CWT) CHALLENGER WORLD TOURS (CWT) TRAVELER REGISTRATION DOCUMENT & TERMS AND CONDITIONS Mail, Fax or Scan/Email To: Challenger World Tours Attn: Gareth Hughes 8263 Flint, Lenexa, KS 66214 USA Phone: 800 878

More information

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury:

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: PATIENT INFORMATION First Name: Last Name: Date of Birth: Gender: Marital Status: S.S.N.

More information

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 Dear Client: It is a pleasure to have you in our practice. We appreciate the opportunity

More information

Baylor Autism Resource Center Applied Behavior Analysis (ABA) Therapy Program

Baylor Autism Resource Center Applied Behavior Analysis (ABA) Therapy Program Baylor Autism Resource Center Applied Behavior Analysis (ABA) Therapy Program Please see the enclosed information and application for more information. The Baylor Autism Resource Center (BARC) Applied

More information

Kendall United/Kendall Soccer Coalition 2014-2015 Season Member Registration Package (Competitive Teams Ages U9-U18) INFORMED CONSENT/INSURANCE NOTICE

Kendall United/Kendall Soccer Coalition 2014-2015 Season Member Registration Package (Competitive Teams Ages U9-U18) INFORMED CONSENT/INSURANCE NOTICE Kendall United/Kendall Soccer Coalition 2014-2015 Season Member Registration Package (Competitive Teams Ages U9-U18) Did you play for Kendall United last year? Yes No Member s Last Name: Member s First

More information

Application Form Masters of Science in Clinical Anatomy

Application Form Masters of Science in Clinical Anatomy College of Medicine and Health Sciences, St. Lucia Application Form Masters of Science in Clinical Anatomy Please complete ALL sections of this application form. A $50 (US) Application Fee (non-refundable)

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

The Octagon. 888 Main Street New York, NY 10044 Tel: (212) 888-8NYC Fax: (212) 202-9647 www.octagonnyc.com LEASE APPLICATION PROCESS

The Octagon. 888 Main Street New York, NY 10044 Tel: (212) 888-8NYC Fax: (212) 202-9647 www.octagonnyc.com LEASE APPLICATION PROCESS The Octagon 888 Main Street Tel: (212) 888-8NYC Fax: (212) 202-9647 www.octagonnyc.com LEASE APPLICATION PROCESS Apt # Rent $ Income Requirements (monthly rent X 40) $ There is a non-refundable fee of

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

(Remainder of this page intentionally left blank)

(Remainder of this page intentionally left blank) THIS AGREEMENT made on and between Glaze and Glaze Properties ( Company ) In consideration of payment of the Monthly Service Fee (as defined below) and so long as Client is not in default of any of its

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C.

J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. PATIENT REGISTRATION - Please PRINT Clearly Patient Name First Middle Last Date of Birth Age Home Address Apt. No. City State Zip code Occupation Social

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information

How did you hear about our services? (Check ONE only)

How did you hear about our services? (Check ONE only) Name: of Visit: Is your visit a MEDICAL or COSMETIC visit? (Check one) How did you hear about our services? (Check ONE only) 1. Newspaper Ad Name of Newspaper: 2. Internet via: Banner Ad Search via pdskin.com

More information

Limited Permit X-ray Technician Bone Densitometry School ID#6020 CLASS NOTIFICATION

Limited Permit X-ray Technician Bone Densitometry School ID#6020 CLASS NOTIFICATION Limited Permit X-ray Technician CLASS NOTIFICATION School information Date: November 6-8, 2015 Time: Friday 7:45 am 7:30 pm Saturday and Sunday 7:30 am 5 pm - Each student s schedule varies Location: 1814

More information

APPLICATION FOR CRIME VICTIM COMPENSATION (Please print clearly and complete the entire form)

APPLICATION FOR CRIME VICTIM COMPENSATION (Please print clearly and complete the entire form) Maryland Criminal Injuries Compensation Board (CICB) Department of Public Safety and Correctional Services 6776 Reisterstown Rd, Ste. 206 Baltimore, MD 21215 410-585-3010 1-888-679-9347 (fax) 410-764-3815

More information

Charlotte Therapy Associates Kate Hayes, MA, CCS, LCAS, LPC Professional Disclosure Statement

Charlotte Therapy Associates Kate Hayes, MA, CCS, LCAS, LPC Professional Disclosure Statement Charlotte Therapy Associates Kate Hayes, MA, CCS, LCAS, LPC Professional Disclosure Statement Professional Competency: I received a Master of Arts degree in Community Counseling from the University of

More information

COOPER & TANIS, P.C.

COOPER & TANIS, P.C. COOPER & TANIS, P.C. Attorneys At Law Robert M. Cooper Leonard D. Tanis Cynthia Feldmiller, Paralegal Joyce M. Bergmann, Of Counsel Nova M. Frank Michael R. Taylor Dear Client: Thank you for selecting

More information

Personal Injury Intake Form

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

More information

Hello there and welcome to the latest 2010 Credit Union QCM email update!

Hello there and welcome to the latest 2010 Credit Union QCM email update! 1 Credit Union QCM Email Blast July 6, 2010 Hello there and welcome to the latest 2010 Credit Union QCM email update! From now up until the night before the race, we ll be sending you these email updates

More information

Shotgun Coaching Workshop Registration and Information Package

Shotgun Coaching Workshop Registration and Information Package Shotgun Coaching Workshop Registration and Information Package Edmonton Conservation Education Centre for Excellence #88, 4003 98 th Street Edmonton, Alberta, Canada T6E 6M8 Phone: (780) 466-6682 or Toll

More information

Date: Student s Name DOB / / Age!!! (First)!! (Middle)!! (Last) Preferred name. Student s School Grade Level Dismissal Time

Date: Student s Name DOB / / Age!!! (First)!! (Middle)!! (Last) Preferred name. Student s School Grade Level Dismissal Time Lafayette Theatre Academy Registration Form Date: Student s Name DOB / / Age!!! (First)!! (Middle)!! (Last) Preferred name Student s School Grade Level Dismissal Time Parent/Guardian/Account Holder s Information

More information

Physical Therapy Services Medical History Form

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

More information

Livingstone 4X4 Challenge Registration Form

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:

More information

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip Today s Date: / / / / Full Legal Name (First, Middle, Last) Date of Birth Age Social Security Number Marital Status Address City State Zip Out of State Address Phone: Home ( ) - Cell ( ) - Email: PREFERRED

More information

5k Run/Walk hosted by the Rochester Hills Government Youth Council

5k Run/Walk hosted by the Rochester Hills Government Youth Council 5k Run/Walk hosted by the Rochester Hills Government Youth Council to benefit the Saturday, June 13, 2015 Bloomer Park Rochester Hills, Michigan 8:30 a.m. 10:30 a.m. Registration Brochure Blessings in

More information

2015 Exhibitor Information

2015 Exhibitor Information 2015 Exhibitor Information You are invited to participate as a professional exhibitor at our 15 th Annual National Conference at Rio All-Suite Hotel & Casino in Las Vegas, Nevada. We expect to have approximately

More information

Your Guide to Support Home Base

Your Guide to Support Home Base Walk H Golf H Bike H Party H Yoga H Concert H Bake Your Guide to Support Home Base Join the Home Team Your Guide to Support Home Base Dear Home Base Program Friend: Thank you for your interest in joining

More information

Dear Parents: We appreciate the opportunity to work with your child and look forward to getting to know your family. Sincerely,

Dear Parents: We appreciate the opportunity to work with your child and look forward to getting to know your family. Sincerely, Dear Parents: Thank you for considering Mobile Therapy Centers of America, LLC (MTC) for your child s therapy needs. At MTC, we strive to provide the highest quality of therapeutic intervention. Our services

More information

Shenandoah Conservatory of Shenandoah University 1460 University Drive Winchester, VA 22601 su.edu/conservatory

Shenandoah Conservatory of Shenandoah University 1460 University Drive Winchester, VA 22601 su.edu/conservatory 1 Shenandoah Conservatory of Shenandoah University 1460 University Drive Winchester, VA 22601 su.edu/conservatory Course Offering for Attendees Developing the Independent Musician July 28-30, 2014 Winchester,

More information

Liverpool Football Club International Academy Soccer Schools 2015 Registration Form

Liverpool Football Club International Academy Soccer Schools 2015 Registration Form Liverpool Football Club International Academy Soccer Schools 2015 Registration Form Day Camp Session Choice: (please check the appropriate box) Day Camp Session 1: Day Camp Session 2: Monday August 3 Friday

More information

CERTIFIED DESIGN FIRM ADMINISTRATOR. APPLICATION FORM for the CDFA Examination

CERTIFIED DESIGN FIRM ADMINISTRATOR. APPLICATION FORM for the CDFA Examination CERTIFIED DESIGN FIRM ADMINISTRATOR APPLICATION FORM for the CDFA Examination Society for Design Administration CDFA Certification Program 8190-A Beechmont Avenue, #276 Cincinnati, OH 45255-6117 Telephone:

More information

Amateur Sports Team & League Liability Insurance Application -No Participant Coverage-

Amateur Sports Team & League Liability Insurance Application -No Participant Coverage- Amateur Sports Team & League Liability Insurance Application -No Participant Coverage- Name of Organization: C/O (Individual Responsible for Insurance): Mailing : City: State: Zip: Phone: ( ) Fax: ( )

More information

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A: Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:

More information

Capture the Paris Wow September 17th - 22nd, 2015. Welcome to Capture the Paris Wow! I look forward to this creative adventure with you in Paris.

Capture the Paris Wow September 17th - 22nd, 2015. Welcome to Capture the Paris Wow! I look forward to this creative adventure with you in Paris. Capture the Paris Wow September 17th - 22nd, 2015 Capture the Wow Registration Form Welcome to Capture the Paris Wow I look forward to this creative adventure with you in Paris. In order to secure your

More information

WE MAY NOT BE ABLE TO TIMELY COMPLETE THIS PROCESS IF WE DO NOT RECEIVE THIS INFORMATON AT LEAST TWO (2) DAYS BEFORE YOUR SCHEDULED COURT APPEARANCE.

WE MAY NOT BE ABLE TO TIMELY COMPLETE THIS PROCESS IF WE DO NOT RECEIVE THIS INFORMATON AT LEAST TWO (2) DAYS BEFORE YOUR SCHEDULED COURT APPEARANCE. We look forward to favorably resolving your traffic ticket/criminal law matter. Simply print this form and fill in the blanks. If this involves a traffic ticket, we understand that you want three things

More information

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment. Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical

More information

Lifetouch Orthopedic Physical Therapy. -- PLEASE PRINT -- Patient Information. Proper Name First Middle Last Name you use

Lifetouch Orthopedic Physical Therapy. -- PLEASE PRINT -- Patient Information. Proper Name First Middle Last Name you use Lifetouch Orthopedic Physical Therapy How did you find out about Lincoln Orthopedic Physical Therapy? Past patient/friend or family Physician Yellow Pages Web Site Location/Street sign Attorney/Nurse Case

More information

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE: PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY

More information

Standard of Electronic Fundraising Practice

Standard of Electronic Fundraising Practice Standard of Electronic Fundraising Practice The Standard of Electronic Fundraising Practice provides practical guidelines for FINZ members for best practice for conducting electronic fundraising activities,

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

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay:

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay: DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD 20770 Phone: (301)313-0425 Fax: (301)313-0435 Patient s Last Name: First Name: MI: Address: City: State: Zip Code:

More information

2015 Nature Explorers Registration Form (Rising 1st to 3rd graders)

2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Information 2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Camper Name: DOB: Parent/Guardian Name(s): Address: City: State: Zip: Home Cell Work Email: *If emergency contact is different

More information

Be An Angel Fund, Inc. 2003 Aldine Bender Houston, Texas 77032 or Fax to : 281-219-7746 or Scan and email to : russ@beanangel.org

Be An Angel Fund, Inc. 2003 Aldine Bender Houston, Texas 77032 or Fax to : 281-219-7746 or Scan and email to : russ@beanangel.org Page 1 of 9 It is our MISSION to improve the quality of life for children with multiple disabilities or profound deafness by providing adaptive equipment and select services to individuals and institutions

More information

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed) Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.

More information

INDIVIDUAL POLICY CHANGE APPLICATION

INDIVIDUAL POLICY CHANGE APPLICATION INDIVIDUAL POLICY CHANGE APPLICATION Instructions: Please complete all applicable areas of this application. Please print using black ink. WPS/Delta Dental of Wisconsin/WPS Health Plan, Inc. d/b/a Arise

More information

Trip Application. Destination: Yaw Tenkorang, Abetifi Region, Ghana, Africa

Trip Application. Destination: Yaw Tenkorang, Abetifi Region, Ghana, Africa Trip Application Destination: Yaw Tenkorang, Abetifi Region, Ghana, Africa Date of Trip: Mission trips are wonderful opportunities to serve and for self-reflection and growth. However, they can also be

More information

After the application has been completed and before you sign it, re-read it carefully to be certain that all information has been properly recorded.

After the application has been completed and before you sign it, re-read it carefully to be certain that all information has been properly recorded. UTAH INDIVIDUAL HEALTH INSURANCE APPLICATION Only for use outside the Federally Facilitated Marketplace A. APPLICANT INFORMATION Please check one of the following boxes: New Application Dependent Addition

More information

PHENIX CITY SPINE & JOINT CENTER

PHENIX CITY SPINE & JOINT CENTER PHENIX CITY SPINE & JOINT CENTER Name: Street Address: Please list ALL medications City: State: Zip: Home Phone: Cell #: Name Of Medication Dosage/ Strength Frequency Date Started Cell Phone Carrier: Race:

More information

Promotional Offers: Early Bird Discount: 10% discount for participants who are registered by May 17 th and have paid in full.

Promotional Offers: Early Bird Discount: 10% discount for participants who are registered by May 17 th and have paid in full. Dear Parents/Guardians, We welcome all of our returning and new campers to our 2014 Summer Camp Programs. We are excited to embark on another summer of fun and learning. From sports and swimming to arts

More information