THIS PERMISSION SLIP IS DUE BY SEPTEMBER 26, Detach and return this portion (with payment) by September 26, 2011

Size: px
Start display at page:

Download "THIS PERMISSION SLIP IS DUE BY SEPTEMBER 26, 2011. Detach and return this portion (with payment) by September 26, 2011"

Transcription

1 Troop 667 Permission Slip (For Scouts) Gateway District Camporee October 7-9, 2011 This permission slip due back with payment to Mrs. Thompson no later than September 26, On October 7-9, 2011 Troop 667 will participate in the Gateway District Camporee. The Fall Camporee is a special event in our district each year. Units will camp out over the weekend Friday through Sunday and Webelos are invited to camp with participating Troops. The location of Camporee this year is Horsetooth Reservoir and to reduce costs, we will be doing some conservation work, along with fun activities! Don t miss this great campout! We will meet at the church on Friday, October 7 at 4:00pm and leave promptly at 4:30. For more information, contact Mr. Shepard ( or djslyd01@aol.com). Date of Campout: October 7-9, 2011 Location: Horsetooth Reservoir near Fort Collins, Colorado Leave from: Church Parking Lot, Friday, October 7, 2011, at 4:00 pm Return to: Church Parking Lot, Sunday, October 9, 2011, around 12:30 pm 20 Per Attendee This includes all camping fees, 3 meals on Saturday and 1 meal on Sunday. THIS PERMISSION SLIP IS DUE BY SEPTEMBER 26, 2011 Detach and return this portion (with payment) by September 26, 2011 (Please print) List everyone who will attend the October 7-9, 2011 Gateway District Camporee. Put each attendee s age and their cost (as show above). Attendee Age Cost (see above) Note: Per Troop policy, no driver reimbursement is being provided for this outing. Total: Want to assist 911 First Aid Teams? Yes, full day Yes, half day No Want to assist archery? Yes, full day Yes, half day No How many Troop tents do you need? Who will use them? Cash Check From Troop Account Treasurer s approval that your account has enough Method of Payment: Whose? Treasurer s Signature: I can transport Scouts (with seat belts): To From Round Trip Cell Phone: Type of vehicle: Number of seat belts (NOT including driver): Important: To transport Scouts, you MUST have auto insurance information on file with the Troop. See Joan Vierra if not. (Please complete other side!) Troop 667 Form C1011-8/0

2 Remember to bring: Parent-Signed Hold Harmless Agreement Completed Medical Form Saw (for cutting limbs and saplings do NOT bring axe or hatchet) Pruning shears Work gloves Water Bottle Personal First Aid Kit Sunscreen, Sunglasses, Chap Stick Good walking shoes - hiking boots recommended Camera (optional) Bug Spray Flashlights w/ extra batteries Compass Mess Kit Rain Gear Toiletries Tent, ground cover, sleeping bag, sleeping pad Clothing for 3 days and 2 nights (dress in layers) Please note: Temps could be 20 degrees or colder at night! Also check your 10 essentials list. My child(ren), listed below, have my permission to attend the October 7-9, 2011 District Camporee Parent/Legal Guardian: Address: Home Phone: Work Phone(s): Cellular: Pager: Phone(s) where I can most likely be reached during this trip: Relationship: Doctor/Clinic: Phone: I, the above listed guardian and the undersigned, hereby give permission for my child(ren), listed above, to be given emergency treatment, including first aid and CPR, by a qualified person. I further authorize and consent to medical, surgical and hospital care, treatment and procedures performed for my child(ren) by a licensed physician or other hospital staff when deemed immediately necessary or advisable by a physician to safeguard my child s health. In the event that I cannot be contacted, I hereby waive my right of informed consent for such treatment. I further give permission for my child(ren) to be transported by ambulance, aid car, air ambulance or other vehicle to an emergency center for treatment. I will assume any and all financial responsibility for the delivery of all such care and services. By signing this permission slip you further agree to promptly retrieve your child AT THE OUTING LOCATION if informed by leaders of the outing that your child is being sent home due to a significant violation of the rules of conduct of Troop 667 while on the outing. Should this occur, you agree that your child will forfeit all monies paid for this outing, and his transportation home will be provided by you in a timely manor and at your expense. Signed:

3 7/21/2011 HOLD HARMLESS AND INDEMNIFICATION AGREEMENT The undersigned hereby agrees to save, keep and hold harmless Larimer County, Larimer County Parks and Open Lands Department, its officers, agents and employees from all claims for property damage, personal injury or wrongful death arising out of, or in connection with, volunteering. By executing this release, the undersigned acknowledges that he/she is fully aware of, and assumes, all of the risks of injury associated with volunteering. This agreement is specific to the Gateway District, Denver Area Council-Fall Camporee from Friday, October 7, 2011 through Sunday, October 9, 2011 at Horsetooth Reservoir in Fort Collins, CO. Date: Signature:_ Address: _ Signature of parent (if child is under the age of 18): Witness:

4 Full name: DOB: Allergies: Emergency contact No.: Annual BSA Health and Medical Record Part A GENERAL INFORMATION High-adventure base participants: Expedition/crew No.: or staff position: Name Date of birth Age Male Address _ Grade completed (youth only) City State Zip Phone No. Unit leader Council name/no. Unit No. Social Security No. (optional; may be required by medical facilities for treatment) Religious preference Health/accident insurance company Policy No. ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE NONE. In case of emergency, notify: Name _ Relationship Address _ Home phone _ Business phone Cell phone Alternate contact Alternate s phone HEALTH HISTORY Are you now, or have you ever been treated for any of the following: Allergies or Reaction to: Female Yes No Condition Explain Asthma Last attack: Diabetes Last HbA1c: Hypertension (high blood pressure) Heart disease (e.g., CHF, CAD, MI) Stroke/TIA Lung/respiratory disease Ear/sinus problems Muscular/skeletal condition Menstrual problems (women only) Psychiatric/psychological and emotional difficulties Behavioral disorders (e.g., ADD, ADHD, Asperger syndrome, autism) Bleeding disorders Fainting spells Thyroid disease Kidney disease Sickle cell disease Seizures Last seizure: Sleep disorders (e.g., sleep apnea) Use CPAP: Yes No Abdominal/digestive problems Surgery Serious injury Other MEDICATIONS List all medications currently used. (If additional space is needed, please photocopy this part of the health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only. Food, Plants, or Insect Bites Immunizations: The following are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. If had disease, put D and the year. If immunized, check the box and the year received. Yes No Date Tetanus Pertussis Diphtheria Measles Mumps Rubella Polio Chicken pox Hepatitis A Hepatitis B Influenza Other (i.e., HIB) Exemption to immunizations claimed (form required). (For more information about immunizations, as well as the immunization exemption form, see Scouting Safely on Scouting.org.) Administration of the above medications is approved by (if required by your state): / Parent/guardian signature and/or MD/DO, NP, or PA signature Be sure to bring medications in sufficient quantities and the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication Printing Rev. 2/2011

5 Part B INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT High-adventure base participants: Expedition/crew No.: or staff position: I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp medical staff, camp management, and/or any physician or health care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R , , etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant s parents or guardian, and/or determination of the participant s ability to continue in the program activities. I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of Scouting activities. I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. Without restrictions. With special considerations or restrictions (list) TALENT RELEASE AGREEMENT I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/ film/videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/ film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America, and I specifically waive any right to any compensation I may have for any of the foregoing. Yes No ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS: You must designate at least one adult. Please include a telephone number. 1. Name Telephone 2. Name Telephone 3. Name Telephone Adults NOT authorized to take youth to and from events: 1. Name 2. Name 3. Name I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating at Philmont, Philmont Training Center, Northern Tier, or Florida Sea Base: I have also read and understand the risk advisories explained in Part D, including height and weight requirements and restrictions, that the participant will not be allowed to participate in applicable high-adventure programs if those requirements and are understand The participant has permission to engage in all high-adventure activities described, except as specifically noted by me not or met. health-care provider. the Participant s name Participant s signature Date Parent/guardian s signature Date (if participant is under the age of 18) Second parent/guardian signature Date (if required; for example, CA) This Annual Health and Medical Record is valid for 12 calendar months. Part B Full name: DOB: Printing Rev. 2/2011

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

Annual Health and Medical Record

Annual Health and Medical Record Annual Health and Medical Record (Valid for 12 calendar months) Policy on Use of the Annual Health and Medical Record In order to provide better care for its members and to assist them in better understanding

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

Schooner SULTANA Middle School 5-Day Trips 2016

Schooner SULTANA Middle School 5-Day Trips 2016 Updated Nov., 2015 Summer Program Forms Packet for Schooner SULTANA Middle School 5-Day Trips 2016 Forms for Your Reference Pick-Up & Drop-Off Information-page 2 Packing List - page 3 Forms That Must Be

More information

Little Einsteins Daycare @ St. Albert Inc. 22 Sir Winston Churchill Avenue, St. Albert, AB T8N 1B4 Phone: 780-486-6740

Little Einsteins Daycare @ St. Albert Inc. 22 Sir Winston Churchill Avenue, St. Albert, AB T8N 1B4 Phone: 780-486-6740 Child s name: Date of registration: Starting Date: Child s age: Male Female Legal Guardian: Mother s Name: Email address: Mother s home phone: Cell # : Mother s place of work: Phone: Is mother allowed

More information

TEEN VOLUNTEER APPLICATION

TEEN VOLUNTEER APPLICATION TEEN VOLUNTEER APPLICATION First Name Last Name Male/Female Date Home Phone Cell Phone Preferred Phone Address Email Want to receive our email newsletter? Y/N City State Zip Code Social Security # or provide

More information

SUMMER ZOO CAMP 2016

SUMMER ZOO CAMP 2016 Scholarships are non-transferable INDIVIDUAL ZOO CAMP SCHOLARSHIP SUMMER ZOO CAMP 2016 APPLICATION AND GUIDELINES APPLICATION DEADLINE March 18, 2016 1 2016 SCHOLARSHIP GUIDELINES Thank you for your interest

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

EMAIL: Reservations are on a first come and paid, first served basis. Make checks payable to: Bonneville School District #93

EMAIL: Reservations are on a first come and paid, first served basis. Make checks payable to: Bonneville School District #93 Pine Basin Outdoor Education Camp 2016 Application Form Thank you for your interest in Bonneville School District s Pine Basin Summer Camp! The camp is for students who have completed 4 th, 5 th or 6 th

More information

Pomperaug District Webelos Overnight Woods October 27-28, 2012. Camp Sequassen New Hartford, CT

Pomperaug District Webelos Overnight Woods October 27-28, 2012. Camp Sequassen New Hartford, CT Pomperaug District Webelos Overnight Woods October 27-28, 2012 Camp Sequassen New Hartford, CT Greetings all Pomperaug District Webelos and Parents! The 2012 WOW will be at Camp Sequassen in New Hartford,

More information

Read this carefully!!!

Read this carefully!!! Our Lady of Hope Church Our Lady of Hope Youth Group MAY 3, 2015 Adult Participants Over 26 Years of Age: Read this carefully!!! If you wish to participate in the Wisconsin Summer Service Trip you MUST

More information

CAMPER HEALTH HISTORY FORM 1

CAMPER HEALTH HISTORY FORM 1 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Dates will attend camp: from to

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

BOY SCOUT APPLICATION

BOY SCOUT APPLICATION 28-209Y BOY SCOUT APPLICATION 500M805 BOY SCOUT APPLICATION I want to be a Scout. I have read the Scout Oath or Promise and the Scout Law. As a Boy Scout, I will meet the obligations of living by the Scout

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

Welcome to the Kroc Center Chicago Summer Day Camp Programs!

Welcome to the Kroc Center Chicago Summer Day Camp Programs! Summer 2015 Welcome to the Kroc Center Chicago Summer Day Camp Programs! If this is your first camp experience, you and your family are about to embark on an exciting and new adventure. If your family

More information

Summer Youth Musical Theater Workshop Registration Form

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,

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

2210 High Tech Road, State College, PA 16803 814-357-6898 fax 814-357-6897 www.pennskates.com

2210 High Tech Road, State College, PA 16803 814-357-6898 fax 814-357-6897 www.pennskates.com Dear Summer Camp Parents, 2210 High Tech Road, State College, PA 16803 814-357-6898 fax 814-357-6897 www.pennskates.com Welcome to our 2015 Summer Day Camp program! Your children will have the opportunity

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

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

Texas A&M University-Corpus Christi Youth Program Medical Emergency Information/Consent for Treatment

Texas A&M University-Corpus Christi Youth Program Medical Emergency Information/Consent for Treatment Texas A&M University-Corpus Christi Youth Program Medical Emergency Information/Consent for Treatment Youth s name: Address: Date of birth: Parent/guardian phone: Home Work Pager/Cellular Medical Information

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

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires

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

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

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

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:

More information

Name: Age: Gender: F M DOB: Address: County: Grade:

Name: Age: Gender: F M DOB: Address: County: Grade: Registration Due June 1, 2015 4-H Teen Camp - Outer Banks 2015 June 22-25, 2015 Thisexcitingcampforourteen44HmemberswilltakeustothecoastJoinusaswelearnaboutduneecology, marinebiology,northcarolinacoastalhistory,teambuilding,andleadershipskills.activitieswillincludeadolphin

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

2015 Summer Sibling Camp Weekend August 14-16th

2015 Summer Sibling Camp Weekend August 14-16th Dear Parents and Siblings, 2015 Summer Sibling Camp August 14 th -16 th We are excited to invite siblings to participate in Camp Sunshine's Sibling Camp Weekend to be held August 14-16th. The weekend will

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

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

All communications will be through email, so please be sure we have your email and your parent s email to avoid miscommunication.

All communications will be through email, so please be sure we have your email and your parent s email to avoid miscommunication. Volunteering as a Teen at St. Mary Note: We appreciate your attention to detail with concerns to completing this application. It is imperative that we be compliant with the various accreditation regulations

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

Quapaw Area Council Boys Scouts of America May 29 May 31 and June 5 June 7, 2015. National Youth Leadership Training Reynolds Training Center

Quapaw Area Council Boys Scouts of America May 29 May 31 and June 5 June 7, 2015. National Youth Leadership Training Reynolds Training Center The National Youth Leadership Training Program (NYLT) is Boy Scouting s premiere youth leadership development program. It is offered in Councils throughout the country. NYLT is an intensive, fun, hands-on,

More information

Department of State Academic Exchanges Participant Medical History and Examination Form

Department of State Academic Exchanges Participant Medical History and Examination Form Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required

More information

without a signed waiver Santa Fe, NM 87506 Fax: 505 820 Student Name: City: Zip: State: Physician's Name: Parent Name(s): Parent Address: City:

without a signed waiver Santa Fe, NM 87506 Fax: 505 820 Student Name: City: Zip: State: Physician's Name: Parent Name(s): Parent Address: City: Please mail application to: Las Campanas Compadres, Inc. 15 Buckskin Circle Santa Fe, NM 87506 Fax: 505 820 2709 Las Campanas Compadres, Inc. Student Application Form Please be sure to sign the waiver

More information

J UNE 15 - AUGUST 7 GRADES (going into) HEADSTART - 7th grade

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

More information

MIAMI DADE COLLEGE MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet

MIAMI DADE COLLEGE MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet Student Name (Print) Student Number The information in this 8 - page packet must

More information

New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.

New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay. The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.

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

STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students

STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS For Students 1. Fill out the student sections on pages 1, 2 and 5. Take all the pages with you to your physical exam appointment. 2. During your physical exam,

More information

Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child)

Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child) Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child) Physician: Date of Birth Gender Social Security PARENT/GUARDIAN S NAME:

More information

Registration and Information Packet

Registration and Information Packet Registration and Information Packet Checklist of items to return Registration and Photo Release Form Emergency Contact and Medical Release Form University of Wyoming Research Agreement Form Contact information

More information

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit. Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)

More information

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

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

More information

Emergency Medical Technician

Emergency Medical Technician Emergency Medical Technician Admission Requirements EMERGENCY MEDICAL TECHNICAL IMPORTANT: PLEASE READ CAREFULLY Classes are held on Tuesday and Thursday nights from 5:00 p.m. until 9:00 p.m. All classes

More information

Motorcycle RiderCourse WAIVERS

Motorcycle RiderCourse WAIVERS Motorcycle RiderCourse WAIVERS General Instructions All pages must be completed and signed. If you have any questions, call (231) 591-5819. Mail completed forms to: Motorcycle Rider Courses, Ferris State

More information

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other: At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We

More information

AnyTown 2013 Delegate Application Form June 10-15, 2013

AnyTown 2013 Delegate Application Form June 10-15, 2013 AnyTown 2013 Delegate Application Form June 10-15, 2013 Application packets due May 20 th Name: Home Phone: Address: City: State: Zip: High School: Cell Phone: Grade Level for Next (2013-14) School Year

More information

Tennessee State University Department of Speech Pathology & Audiology Intensive Articulation, Fluency, Language & Diagnostics Summer Speech Camp

Tennessee State University Department of Speech Pathology & Audiology Intensive Articulation, Fluency, Language & Diagnostics Summer Speech Camp Tennessee State University Department of Speech Pathology & Audiology Intensive Articulation, Fluency, Language & Diagnostics Summer Speech Camp Speech Pathology and Audiology will provide intensive therapeutic

More information

AMAZING BIKE CAMP JUNE 22 26, 2015

AMAZING BIKE CAMP JUNE 22 26, 2015 AMAZING BIKE CAMP JUNE 22 26, 2015 REGISTRATION FORM The Children s Institute of Pittsburgh partners with icanshine (formerly Lose the Training Wheels) to offer this unique camp that teaches children with

More information

Kentucky District Junior Leadership Training Academy Rotary Ranger Reservation Glasgow Kentucky

Kentucky District Junior Leadership Training Academy Rotary Ranger Reservation Glasgow Kentucky Kentucky District Junior Leadership Training Academy Rotary Ranger Reservation Glasgow Kentucky FOR OFFICE US E POSTMARKED: PAID: BALANCE DUE: Please select the camp you are attending by checking the correct

More information

William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C

William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C 275 Collier Road NW Suite 470 Atlanta, GA 30309 William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C www.atlantabreastcare.com Phone:

More information

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

MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information

MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information MONTESANO PHYSICAL THERAPY, INC. Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S.

More information

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

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

Youth Ministry Registration Form. Please complete this form for all children participating in children s ministry.

Youth Ministry Registration Form. Please complete this form for all children participating in children s ministry. Youth Ministry Registration Form Please complete this form for all children participating in children s ministry. Last Name First Name DOB Male or Female Parent(s)/Guardian(s): Street Address: City: State:

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

Dear Preschool Parent:

Dear Preschool Parent: Dear Preschool Parent: Thank you for choosing Monument Academy Preschool, Tri-Lakes premier Core Knowledge Pre-school. We are honored that you have chosen for us to help you in providing excellent care

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

For high school teens Time to escape and just BE U BE with God BE loved by God BE forgiven by God BE changed Be with Friends (and make new ones)

For high school teens Time to escape and just BE U BE with God BE loved by God BE forgiven by God BE changed Be with Friends (and make new ones) What: For high school teens Time to escape and just BE U BE with God BE loved by God BE forgiven by God BE changed Be with Friends (and make new ones) Where: Cuyahoga Valley Environmental Education Center

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

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

Welcome Letter. Please request the current Tuition and Fee Schedule Form directly from the campus location you are interested in enrolling your child.

Welcome Letter. Please request the current Tuition and Fee Schedule Form directly from the campus location you are interested in enrolling your child. Welcome Letter Dear Parent, Thank you for considering Castle Montessori for your child! Castle Montessori's academic philosophy is based on authentic Montessori principles for students ranging from toddlers

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

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

RARITAN BAY AREA YMCA

RARITAN BAY AREA YMCA Dear Applicant, Enclosed please find the Youth Leaders & Junior Counselor In Training Application and the Camp Registration Packet. Please complete the application and return all documents with your $100.00

More information

Beach Cities Medical Weight Loss

Beach Cities Medical Weight Loss Beach Cities Medical Weight Loss PATIENT HEALTH HISTORY Name: Address: City/State: Zip: Phone: (home) Cell: Date of Birth: Occupation: Driver s License # Expiration: Emergency Contact Name: Relationship:

More information

CAMPWOW2015. HillSpring Church Youth and Children s 2015 Summer Camp Information Packet. What to Pack/What Not to Pack.

CAMPWOW2015. HillSpring Church Youth and Children s 2015 Summer Camp Information Packet. What to Pack/What Not to Pack. HillSpring Church Youth and Children s 2015 Summer Camp Information Packet Page 2 Camp WOW Summer Camp Dates and Cost Page 3 Info about Laser Tag and Camp WOW Cash Card Page 4 What to Pack/What Not to

More information

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your

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

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all

More information

POLICE ATHLETIC LEAGUE

POLICE ATHLETIC LEAGUE POLICE ATHLETIC LEAGUE The Police Athletic League (P.A.L.) is a recreation-oriented juvenile crime prevention program that relies heavily on athletics and recreational activities to create and cement the

More information

Big House 2015. Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th

Big House 2015. Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th Big House 2015 June 11-14 Bellville, TX Big House is a summer mission

More information

Orthopedic Specialists Of SW FL New Patient Information Form

Orthopedic Specialists Of SW FL New Patient Information Form Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason

More information

Continuing Education Allied Health Programs Certified Nurse Aide (CNA) - Student Requirements:

Continuing Education Allied Health Programs Certified Nurse Aide (CNA) - Student Requirements: Certified Nurse Aide (CNA) - Student Requirements: STAFF VERIFICATION: DATE: COMMENTS: Desired Class Date: _ Session: CEQ Name: Address: City:, Texas Zip: Phone #: Alt #: Email: Students entering the Certified

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

Counselor Certification Program

Counselor Certification Program Counselor Certification Program 4-H Adventure Camp Counselors have a unique opportunity to meet and work with teens, adults, and youth while having a fun outdoor experience and developing leadership skills.

More information

Eighth Graders Israel Experience May 7-19- 2014 APPLICATION

Eighth Graders Israel Experience May 7-19- 2014 APPLICATION please attach photo Part I: Applicant Information Eighth Graders Israel Experience May 7-19- 2014 APPLICATION Applicant's name (As appears on passport) Last first middle what do you want to be called?

More information

Nearest Relative Information (Not in same household)

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

More information

EZ REHAB SOLUTIONS: Patient Intake Information

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

More information

PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:

PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age: Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,

More information

LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION

LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION A-02 form.patient.demographic.information Rev. (01/14) DATE: SIGNATURE: PHYSICIAN (PLEASE PRINT) LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION PATIENT'S FULL NAME ADDRESS APT. # CITY STATE

More information

Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL

Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline County Public School system, your child has access to the School-Based

More information

THE FURNACE Where the Best Become Better National Youth Leadership Training NYLT June 9 to June 15, 2013 - Camp McKinley, Lisbon, OH

THE FURNACE Where the Best Become Better National Youth Leadership Training NYLT June 9 to June 15, 2013 - Camp McKinley, Lisbon, OH Dear Junior Leader: THE FURNACE Where the Best Become Better National Youth Leadership Training NYLT June 9 to June 15, 2013 - Camp McKinley, Lisbon, OH Congratulations on being nominated by your Troop

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

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

Trinitas School of Nursing Health Clearance Information

Trinitas School of Nursing Health Clearance Information Trinitas School of Nursing Health Clearance Information Students are required to have health clearance before they are allowed to register for NURE 131 and higher courses. All NURE 132, NURE 231, NURE

More information

1. COMPLETE & SUBMIT YOUR APPLICATION

1. COMPLETE & SUBMIT YOUR APPLICATION Dear Prospective Young At Art Museum Teen Volunteer, YAA Teen Leadership Program Sponsored by American Express Charitable Fund Thank you for your interest in volunteering with Young At Art Museum. The

More information

Grade 4 and 5 Ski Camp Monday-Friday, February 1-5, 2016 Yong Pyong Ski Resort, Korea / www.yongpyong.co.kr

Grade 4 and 5 Ski Camp Monday-Friday, February 1-5, 2016 Yong Pyong Ski Resort, Korea / www.yongpyong.co.kr Grade 4 and 5 Ski Camp Monday-Friday, February 1-5, 2016 Yong Pyong Ski Resort, Korea / www.yongpyong.co.kr December 4, 2015 Dear Grade 4 and 5 Parents, I am pleased to inform you that Dwight School Seoul

More information

2016 Camp Confirmation Packet

2016 Camp Confirmation Packet GAME BREAKER Lacrosse Camps 2016 Camp Confirmation Packet University of South Florida Tampa, FL June 13-16, 2016 Dear Parents, Thank you for registering for our 2016 GameBreaker Lacrosse Camp! We hope

More information

PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI

PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI 275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME

More information

ANIMAL CARE AND CONTROL Community Service Starter Packet

ANIMAL CARE AND CONTROL Community Service Starter Packet Attachment 1 ANIMAL CARE AND CONTROL Community Service Starter Packet ALL PAPEWORK MUST BE SIGNED, COMPLETED, RETURNED AND APPROVED PRIOR TO STARTING YOUR COMMUNITY SERVICE HOURS AT ANIMAL CARE AND CONTROL.

More information

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION Today s date: / / EMAIL: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. SS#: - - Birth date: Sex: [ ]

More information

TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD

TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD Please complete this form to the best of your ability and bring it to your Physician, Nurse Practitioner or Physician s Assistant for your physical examination.

More information

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient

More information

Young Women - Camp Registration Form

Young Women - Camp Registration Form Young Women - Camp Registration Form Tuesday July 24 - Saturday July 28 Be still, and know that I am God (D&C 101:16) Cost of Registration - $130 Young Women Due by Sunday, May 20 th Camper Name Date of

More information