Chang Scholarship Student Information

Size: px
Start display at page:

Download "Chang Scholarship Student Information"

Transcription

1 Chang Scholarship Student Information The mission of the Davis Schools Orchestral Music Association (DSOMA) is to support music students and the music program in general. Our music teachers believe that the best way for a student to improve is to study one-on-one with a private tutor. Donations from the Robert and Yinette Chang Family Fund provide scholarships for private lessons to students participating in the DJUSD strings program. The Chang Scholarship Program, administered by the Board of Directors of DSOMA, awards scholarships intending to supplement a long-term commitment to private lessons and musical excellence. Tutors are high school musicians playing in the DHS Orchestral Program; the DHS Music Director approves all tutors. The Chang Scholarship Program Coordinator matches students with tutors. DSOMA makes scholarship payments directly to the tutor. Scholarships are valued up to $300 each an amount sufficient to pay for 30 weekly lessons of 30 minutes duration. Students must reapply after completing 30 lessons. Student applicants must be in 4 th, 5 th, 6 th, 7 th, or 8 th grade and participating in DJUSD Elementary or Junior High Orchestra. A DSOMA committee evaluates the applications and makes the final decisions. The committee uses the following criteria for selecting scholarship recipients: a) demonstrated financial need; b) music teacher recommendation 1. potential for musical growth; 2. past participation, attitude, responsibility, and maturity; c) commitment to the music program from both student and parent(s); and d) active interest and support of parent(s) to the student and to the music program. Applicants must complete the following forms: a) Chang Scholarship Student Application; and b) Chang Scholarship Student Music Teacher Recommendation (provided to music teacher by applicant and mailed to DSOMA by music teacher); and c) Chang Scholarship Student Waiver of Liability & Indemnification Agreement The completed forms must be submitted to: DSOMA, Chang Scholarship Program, P.O. Box 1305, Davis, CA Applicants will be notified within four weeks of receipt of the application. For more information or assistance, contact: Chang Scholarship Program Coordinator at or

2 Chang Scholarship Student Application To be completed by student s parent/guardian. Please print. Student name: Parent/guardian name: Address: City: Zip: Phone: Student grade: School: Instrument: a) Is student active in music groups outside of school? Yes No If yes, which ones? b) Does student take private lessons? Yes No If yes, please explain why you are interested in this program: c) Please briefly explain your financial need: d) Please briefly explain how your child will benefit from private lessons and this scholarship: e) Is there any other information you wish to provide to the Chang Scholarship Committee? Parent signature: Date: Return: DSOMA, Chang Scholarship Program, P.O. Box 1305, Davis, CA

3 CHANG SCHOLARSHIP MUSIC TEACHER RECOMMENDATION To be completed and submitted to DSOMA by music teacher The Davis Schools Orchestral Music Association offers scholarships to students to take private lessons from approved DHS music tutors. The scholarships are available to students in grades 4 through 8 who have a financial need and who have demonstrated commitment to music. One part of the process is to obtain an evaluation from the music instructor. Your opinion is a vital part of the application and will be carefully considered. Thank you for taking the time to evaluate this student. After completing this form, please return it to the Chang Scholarship Coordinator by at or using the DSOMA post office box, P.O. Box 1305, Davis, CA Student name: On a scale from 1 to 5, please rate this student's habits as they relate to playing his/her instrument (1 = very little; 3 = average; 5 = very much) - This student shows potential for musical growth - This student is willing to practice in order to improve his/her musical abilities - This student shows respect for his/her instrument - This student shows responsibility by being on time, having his/her instruments, music and accessories when showing up for his/her lesson - This student shows a positive attitude and willingness to learn - This student appears committed to the music program - This student has his/her parents active support and interest for the music program (see next page)

4 Please describe this student's overall maturity and potential for taking advantage of a private lesson scholarship: Additional Comments: Would you recommend this student to receive the scholarship? No With reservation Without reservation Enthusiastically Signature of Teacher: Date: Return: DSOMA, Chang Scholarship Program, P.O. Box 1305, Davis, CA 95617

5 Chang Scholarship Student Waiver of Liability & Indemnification Agreement Student s name: I agree my minor child will receive private music lessons through the Chang Scholarship Program. I understand and agree to the following for myself and my minor child: Waiver and Discharge I waive, release, and discharge Davis Schools Orchestral Music Association (DSOMA) and all of its officers, directors, members, and agents from any and all claims and damages from personal injury, death, or property damage which I may sustain or which may occur in connection with Chang Scholarship private lessons, including claims and damages resulting from intentional acts. I discharge DSOMA from any and all liability connected in any way with providing lessons; Assumption of Risk I assume any and all risks of injury, death, or property damage related to providing music lessons, including those caused by intentional acts; Indemnification I indemnify and hold DSOMA harmless from any loss, liability, damage, cost or expense, including litigation, which DSOMA incurs as a result of any injury or property damage which I sustain or cause, in whole or in part, in connection with lessons; Litigation Cost I will make good any loss, damage, or cost DSOMA pays for litigation arising from any claim by me, or anyone else on my behalf, in connection with lessons; and Heirs and Assigns This waiver, release, assumption of risk, and indemnification agreement is binding on my heirs and assigns. I certify that I have custody or that I am the legal guardian of the student. I have carefully read this Waiver of Liability & Indemnification Agreement and I fully understand that the agreement applies to me and my minor child. Parent/Guardian signature: Date: Return to: DSOMA, Chang Scholarship Program, P.O. Box 1305, Davis, CA 95617

VIVA! Peer Tutors 2012 Health Literacy Video Contest COPYRIGHT FORM

VIVA! Peer Tutors 2012 Health Literacy Video Contest COPYRIGHT FORM COPYRIGHT FORM Every entrant must complete and submit this form together with ALL OTHER FORMS. Please do not send separately. All forms must be received by March 19, 2012. Please complete this form and

More information

Karen Ritch. February 28, 2015. Re: Youth Advisory Council Application-Due April 30, 2015. Dear Educators and Parents:

Karen Ritch. February 28, 2015. Re: Youth Advisory Council Application-Due April 30, 2015. Dear Educators and Parents: February 28, 2015 Re: Youth Advisory Council Application-Due April 30, 2015 Dear Educators and Parents: Longview World of Wonders is a community organization dedicated to our mission to inspire a life-long

More information

LATE PAYMENT FEES WITHDRAWAL FROM THE PROGRAM THIRD PARTY (SPLIT) PAYMENTS RESPONSIBLE PARTY. Parent/Guardian Agreement: Dear Parents and Guardians,

LATE PAYMENT FEES WITHDRAWAL FROM THE PROGRAM THIRD PARTY (SPLIT) PAYMENTS RESPONSIBLE PARTY. Parent/Guardian Agreement: Dear Parents and Guardians, Dear Parents and Guardians, In order to simplify and provide better service to everyone, Rancho Simi Recreation and Park District ( the District ) has implemented the following payment processing procedures

More information

Release of Liability. Printed Name of Participant:

Release of Liability. Printed Name of Participant: Release of Liability IN CONSIDERATION of being given the opportunity to participate in any USRowing activity, including scheduled, supervised club activities, and registered regattas, during the policy

More information

June 4, 2015. Dear Parents,

June 4, 2015. Dear Parents, June 4, 2015 Dear Parents, We are excited to offer a special opportunity for your students for the 2015-2016 school year from the Vetri Foundation and the Free Library of Philadelphia. The Free Library

More information

Rebecca s House. Rebecca s House Eating Disorder Foundation Scholarship Fund Application Packet Page 1

Rebecca s House. Rebecca s House Eating Disorder Foundation Scholarship Fund Application Packet Page 1 Rebecca s House Eating Disorder Treatment Partial Scholarship Application Packet Rebecca s House Eating Disorder Foundation Scholarship Fund Application Packet Page 1 T a b l e o f C o n t e n t s M i

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

YALE UNIVERSITY CITIZENS, THINKERS, WRITERS: REFLECTIONS ON CIVIC LIFE APPLICATION FOR SUMMER 2016

YALE UNIVERSITY CITIZENS, THINKERS, WRITERS: REFLECTIONS ON CIVIC LIFE APPLICATION FOR SUMMER 2016 NOTE: This application can also be completed online at http://humanities.yale.edu/apply APPLICANT INFORMATION First Name Last Name M.I. Street Address Apt/Unit # City State ZIP Code Student Cell Phone

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

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

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

Midwest Cheer Elite All-star Hip Hop Information 2015-2016

Midwest Cheer Elite All-star Hip Hop Information 2015-2016 Midwest Cheer Elite All-star Hip Hop Information 2015-2016 Welcome to Midwest Cheer Elite, Inc. We are delighted that you have chosen to become a part of one of the top All-Star programs in the Midwest!

More information

INSTRUCTIONS FOR COMPLETING REGISTRATION. 2. Fill out the forms completely with necessary information and signatures:

INSTRUCTIONS FOR COMPLETING REGISTRATION. 2. Fill out the forms completely with necessary information and signatures: INSTRUCTIONS FOR COMPLETING REGISTRATION 1. Print out the Waiver of Liability, Medical Release Form and Participant Information Sheet attached to this document 2. Fill out the forms completely with necessary

More information

Artist Prospectus for MCH Healing Arts Gallery

Artist Prospectus for MCH Healing Arts Gallery Artist Prospectus for MCH Healing Arts Gallery MISSION The MCH Healing Arts Gallery has been established in the Fall of 2011 by a group of enthusiastic Staff, Artists and Volunteers forming the MCH Healing

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

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

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

CHICAGO RUNNING TOURS & MORE, LLC WAIVER AND RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT PLEASE REVIEW THOROUGHLY BEFORE SIGNING

CHICAGO RUNNING TOURS & MORE, LLC WAIVER AND RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT PLEASE REVIEW THOROUGHLY BEFORE SIGNING CHICAGO RUNNING TOURS & MORE, LLC WAIVER AND RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT PLEASE REVIEW THOROUGHLY BEFORE SIGNING The undersigned, in consideration of being permitted to participate

More information

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

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

More information

NORTH SHORE SCHOOL DISTRICT COMPUTER NETWORK ACCEPTABLE USE POLICY. Please read the following before signing the attached legally binding contract.

NORTH SHORE SCHOOL DISTRICT COMPUTER NETWORK ACCEPTABLE USE POLICY. Please read the following before signing the attached legally binding contract. NORTH SHORE SCHOOL DISTRICT COMPUTER NETWORK ACCEPTABLE USE POLICY Please read the following before signing the attached legally binding contract. Introduction Internet access is now available to students,

More information

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

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

More information

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

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

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

More information

NORTHWEST PARK & NATURE CENTER Junior Counselor Certification Program 2015

NORTHWEST PARK & NATURE CENTER Junior Counselor Certification Program 2015 Junior Counselor Certification Program 2015 The Junior Counselor Certification Program (JCCP) is a pre-counselor training program for youth ages 14-17, which focus upon gaining the skills necessary to

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

2015-16 Insurance Information Insurance coverage

2015-16 Insurance Information Insurance coverage 2015-16 Insurance Information Insurance coverage At USA Wrestling, our top priorities are safety and security. That's why we make sure you're covered by General Liability, Accidental Medical Expense, and

More information

Students will have an instructor of record for this course. The instructor s requirements include:

Students will have an instructor of record for this course. The instructor s requirements include: Guidelines for Receiving MBA Internship Credit Internships are important for students to gain experience before starting or while completing their studies in the MBA program. They can be rewarding and

More information

2015 Tournament Entry Form

2015 Tournament Entry Form Mississippi MS HIGH SCHOOL BASS NATION 2015 Tournament Entry Form ONE FORM PER TEAM Angler #1 Name: Event Location: Angler #2 Name: School Club Name: Team Advisor Name: Ph# Address: City: State: Zip Code:

More information

2016 Bowdoin Summer Art Camp Registration

2016 Bowdoin Summer Art Camp Registration 2016 Bowdoin Summer Art Camp Registration Hours and Location Bowdoin Summer Art Camp will run for four weeks from June 27 th through July 22 th. The times and length of each session vary. Please refer

More information

Application Form June 14-19, 2015 PLEASE fill out online (and print) or write neatly on all parts of the form.

Application Form June 14-19, 2015 PLEASE fill out online (and print) or write neatly on all parts of the form. Application Form June 14-19, 2015 PLEASE fill out online (and print) or write neatly on all parts of the form. Part 1: Student Information Name: Gender: M F Street Address: City: State: Zip: Home Phone:

More information

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

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

More information

Please list below any medical conditions and/or allergies the DBA Faculty should be

Please list below any medical conditions and/or allergies the DBA Faculty should be 2015-2016 Registration Form Name Of Child(ren): Date of Birth: Address Where Child Resides: Mailing Address (if different from above): Home Phone Number: Please check next to whom the child resides with:

More information

TEXAS A&M INTERNATIONAL UNIVERSITY

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

More information

3004 S. Rancho Dr. Las Vegas, NV. 89102 * PH: 702-220-5614 * www.tevakanui.com

3004 S. Rancho Dr. Las Vegas, NV. 89102 * PH: 702-220-5614 * www.tevakanui.com 2009/2010 Policy Agreement I have received a copy of the 2009/2010 studio policy and current class schedule. I agree to adhere to all studio policies as contained in this document and explained to me.

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

ARCADIA YOUTH RODEO ASSOCIATION, INC. 124 Heard Street, Arcadia, Florida 34266 863-494-2014 2015-2016 SEASON MEMBERSHIP APPLICATION

ARCADIA YOUTH RODEO ASSOCIATION, INC. 124 Heard Street, Arcadia, Florida 34266 863-494-2014 2015-2016 SEASON MEMBERSHIP APPLICATION 2015-2016 SEASON MEMBERSHIP APPLICATION MEMBER INFORMATION: BACK TAG # ISSUED: MEMBER NAME: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CEL #: E-MAIL ADDRESS: (Please send newsletter via: Mail E-Mail ) DATE

More information

2014 Fort Worth Regional Science and Engineering Fair, University of Texas at Arlington, RadioShack. Media Release Form

2014 Fort Worth Regional Science and Engineering Fair, University of Texas at Arlington, RadioShack. Media Release Form 2014 Fort Worth Regional Science and Engineering Fair, University of Texas at Arlington, RadioShack Media Release Form I hereby consent to and authorize the use and reproduction by Fort Worth Regional

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

Bartow County C.E.R.T.

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

More information

Wilderness First Aid. Basler Center for Physical Activitiy. Saturday Feb. 25 - Sunday Feb. 26. Non Credit Instruction. Wilderness First Aid

Wilderness First Aid. Basler Center for Physical Activitiy. Saturday Feb. 25 - Sunday Feb. 26. Non Credit Instruction. Wilderness First Aid Non Credit Instruction Saturday Feb. 25 - Sunday Feb. 26 Wilderness First Aid Offered at ETSU through Landmark Learning. Saturday Feb. 25 through Sunday Feb. 26 8 a.m 5 p.m. Wilderness First Aid $125 ETSU

More information

JUNE 20 24, 2016 VIDEO GAME DEVELOPMENT SUMMER CAMP

JUNE 20 24, 2016 VIDEO GAME DEVELOPMENT SUMMER CAMP Attention upcoming 7 th - 10 th graders: You are invited to join the IT and Web Design faculty at Carteret Community College for an action packed week of Video Game Design, Development, and Play. JUNE

More information

~LOTUS GUNWORKS OF SOUTH FLORIDA, LLC~ RELEASE, WAIVER, INDEMNIFICATION, HOLD HARMLESS, AND ASSUMPTION OF THE RISK AGREEMENT

~LOTUS GUNWORKS OF SOUTH FLORIDA, LLC~ RELEASE, WAIVER, INDEMNIFICATION, HOLD HARMLESS, AND ASSUMPTION OF THE RISK AGREEMENT ~LOTUS GUNWORKS OF SOUTH FLORIDA, LLC~ RELEASE, WAIVER, INDEMNIFICATION, HOLD HARMLESS, AND ASSUMPTION OF THE RISK AGREEMENT WHEREAS, in return for being allowed to enter Lotus Gunworks, Lotus Gun Range

More information

All Students - Please complete items 1-5 All paperwork must have original signatures and be readable. No partial submissions will be accepted.

All Students - Please complete items 1-5 All paperwork must have original signatures and be readable. No partial submissions will be accepted. Independent Study Physical Education (I.S.P.E.) The following items must be on file before your Independent Study application is complete. (1) Complete the online I.S.P.E. contract (keep a copy for your

More information

Independent Contract Instructor Handbook and Proposal City of Lathrop Parks & Recreation Department

Independent Contract Instructor Handbook and Proposal City of Lathrop Parks & Recreation Department Independent Contract Instructor Handbook and Proposal City of Lathrop Parks & Recreation Department 390 Towne Centre Drive Lathrop, CA 95330 Phone (209) 941-7370 Fax (209) 941-7379 www.ci.lathrop.ca.us

More information

Your agent cannot make health care decisions for you. You may execute a Health Care Proxy to do this.

Your agent cannot make health care decisions for you. You may execute a Health Care Proxy to do this. NEW YORK PUBLIC EMPLOYEE RETIREMENT SYSTEM SPECIAL DURABLE POWER OF ATTORNEY PREAMBLE: This is a Public Retirement System Special Power of Attorney prepared pursuant to General Obligations Law Article

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

Camp Waiver Packet. Student Signature: Date: - - Parent Signature: Date: - - (Parent s signature is required if the student is under the age of 18)

Camp Waiver Packet. Student Signature: Date: - - Parent Signature: Date: - - (Parent s signature is required if the student is under the age of 18) Camp Waiver Packet You should have completed the initial registration and payment process on our website at www.centennialaviationacademy.com prior to completing this packet. If you have not done so, please

More information

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

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

More information

OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO

OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO SCHOOL MEDICATION PROCEDURES Parents/guardians have the primary respomibility for (he adminislration of medical ion to their children. The administration

More information

Georgia Tech North Ave. NW Atlanta Ga. 30332

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

More information

Travel Grant Application Fall 2015 October 23 Deadline

Travel Grant Application Fall 2015 October 23 Deadline Travel Grant Application Fall 2015 October 23 Deadline The USUAA Student Travel Scholarship program was created by USUAA Student Government and is funded entirely by student fees. Scholarships are awarded

More information

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

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

More information

LOCAL 372 N.Y.C. BOARD OF EDUCATION EMPLOYEES SHAUN D. FRANCOIS I, PRESIDENT

LOCAL 372 N.Y.C. BOARD OF EDUCATION EMPLOYEES SHAUN D. FRANCOIS I, PRESIDENT LOCAL 372 N.Y.C. BOARD OF EDUCATION EMPLOYEES SHAUN D. FRANCOIS I, PRESIDENT SCHOLARSHIP APPLICATION 2016 2016 LOCAL 372 SCHOLARSHIP FUND REGULATIONS GOVERNING USE OF SCHOLARSHIPS Scholarship awards of

More information

North Star Online School Enrollment Application In District Students 5450 Riggins Ct Reno, NV 89502 (775) 353-6900 Fax: 775-689-2537

North Star Online School Enrollment Application In District Students 5450 Riggins Ct Reno, NV 89502 (775) 353-6900 Fax: 775-689-2537 North Star Online School Enrollment Application In District Students 5450 Riggins Ct Reno, NV 89502 (775) 353-6900 Fax: 775-689-2537 Thank you for your interest in North Star Online School for your student

More information

Please read the waiver carefully. If you have any questions or concerns contact registration@aiusa.org.

Please read the waiver carefully. If you have any questions or concerns contact registration@aiusa.org. Amnesty International USA sponsors special enrichment events for youth leaders as a means of providing a comprehensive and diverse learning environment to further their understanding of and participation

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

1. Account Owner. 2. Plan(s) Included. 3. Existing Authorized Agents. Helpful To Know. Questions? Go to Mysavingsatwork.com or call 1-800-343-0860.

1. Account Owner. 2. Plan(s) Included. 3. Existing Authorized Agents. Helpful To Know. Questions? Go to Mysavingsatwork.com or call 1-800-343-0860. Questions? Go to Mysavingsatwork.com or call 1-800-343-0860. Trading Authority Workplace Investing Retirement Plans Use this form to grant a third party limited trading authority, which includes the ability

More information

Aviation Summer Camp Scholarship

Aviation Summer Camp Scholarship Aviation Summer Camp Scholarship sponsored by the Experimental Aircraft Association Chapter 62 What is the EAA Air Academy? Each summer, the Experimental Aircraft Association (EAA) Aviation Foundation

More information

MAKE A SPLASH. Fall Swim Lessons ISLANDS FAMILY YMCA

MAKE A SPLASH. Fall Swim Lessons ISLANDS FAMILY YMCA MAKE A SPLASH Fall Swim Lessons ISLANDS FAMILY YMCA The Islands YMCA is proud to offer the lesson of a lifetime by teaching swimming skills! During the fall/winter we will be offering Private Swim lessons

More information

Prairie Flight Camp. July 19-24. Prairie School of Mission Aviation. Box 4000 Three Hills, AB, Canada T0M 2N0 403.443.2349

Prairie Flight Camp. July 19-24. Prairie School of Mission Aviation. Box 4000 Three Hills, AB, Canada T0M 2N0 403.443.2349 Prairie Flight Camp 2015 July 19-24 Box 4000 Three Hills, AB, Canada T0M 2N0 403.443.2349 Our Purpose s program exists to prepare mission-minded pilots for Global Ministry. Our graduates are currently

More information

Enrollment Application 2014-2015

Enrollment Application 2014-2015 Enrollment Application 2014-2015 Student Name: Date: Current Grade Level: Current School: Date of College Track Presentation: Submit Application by: Checklist of items that must be returned to College

More information

Chatham Community Center Fitness Room

Chatham Community Center Fitness Room Chatham Park & Recreation 702 Main Street Chatham, MA 02633 Telephone Fax (508) 945-5159 www.chathamcommunitycenter.com Fitness Room Hours of Operation: Monday Saturday 8:00 A.M. to 9:00 P.M. Sundays 1-5:00

More information

I UNDERSTAND THAT THESE RISKS MAY RESULT IN INJURY OR EVEN DEATH.

I UNDERSTAND THAT THESE RISKS MAY RESULT IN INJURY OR EVEN DEATH. CORNELL COLLEGE S RELEASE, WAIVER AND INDEMNIFICATION AGREEMENT FOR NON-EMPLOYEES ATTENDING FOR CREDIT ACTIVITIES OFFERED BY NON- EIIA MEMBER INSTITUTIONS OR OTHER THIRD PARTIES OR INDEPENDENT STUDY OR

More information

INTERNATIONAL LEADERSHIP OF TEXAS

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

More information

SANTA BARBARA SCHOOL DISTRICTS, SECONDARY EDUCATION INDEPENDENT STUDY PHYSICAL EDUCATION. HOLD HARMLESS AGREEMENT (Agency/Instructor/Coach)

SANTA BARBARA SCHOOL DISTRICTS, SECONDARY EDUCATION INDEPENDENT STUDY PHYSICAL EDUCATION. HOLD HARMLESS AGREEMENT (Agency/Instructor/Coach) SANTA BARBARA SCHOOL DISTRICTS, SECONDARY EDUCATION INDEPENDENT STUDY PHYSICAL EDUCATION HOLD HARMLESS AGREEMENT (Agency/Instructor/Coach) (Agency/Instructor/Coach) hereby agrees to defend, indemnify and

More information

PAGE EDUCATION FOUNDATION P A G E G R A N T APPLICATION 2015-2016. P.O. Box 581254, Minneapolis, MN 55458 www.page-ed.org

PAGE EDUCATION FOUNDATION P A G E G R A N T APPLICATION 2015-2016. P.O. Box 581254, Minneapolis, MN 55458 www.page-ed.org PAGE EDUCATION FOUNDATION P A G E G R A N T APPLICATION 2015-2016 P.O. Box 581254, Minneapolis, MN 55458 PAGE EDUCATION FOUNDATION 2015-2016 Page Grant Application Information HISTORY: A young person s

More information

Northstar Travel & Associates

Northstar Travel & Associates Northstar Travel & Associates TRAVEL BOOKING & PASSENGER REQUEST FORM (Please use 1 application form for each participant) NOTE: Please include a photocopy of the first page (ie. photo-page ) of your passport

More information

"Link to the Future Scholarships"

Link to the Future Scholarships ATTENTION ATTENTION ATTENTION ******** High School Seniors "Link to the Future Scholarships" awarded by: North Broward County Chapter of The Links, Incorporated For Students Enrolling in College: (Community,

More information

If your child fails the screening, you will be informed of test results. Please direct any questions to the. school nurse at.

If your child fails the screening, you will be informed of test results. Please direct any questions to the. school nurse at. If your child passes the vision screening, you may not be contacted by the school nurse. A vision screening provides only a snapshot of how your child performs on the day the test was administered and

More information

Student Board of Directors Application Packet

Student Board of Directors Application Packet Dear Student, Thank you for your interest in participating in the Student Board of Directors Program at the Federal Reserve Bank of Kansas City, Denver Branch. Please complete this application packet,

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

Youth Programs Registration Form Summer of Service (SOS) 2015

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

More information

SPECIAL KIDS PROGRAM. Program Description and Guidelines

SPECIAL KIDS PROGRAM. Program Description and Guidelines To ensure that all Minnesota children in grades K-12 and children from historically under served populations have access to the computer technology needed to develop the skills, knowledge and confidence

More information

2014 July 1, 2013 - June 30, 2014

2014 July 1, 2013 - June 30, 2014 2014 July 1, 2013 - June 30, 2014 page 1 of 3 BUSINESS ENTITY TAX CREDIT APPLICATION TAX CREDITS FOR CONTRIBUTIONS TO SCHOLARSHIP ORGANIZATIONS - RIGL 44-62 APPLICATIONS WILL BE ACCEPTED STARTING JULY

More information

COMMUNITY COLLEGE STUDENTS SCHOLARSHIPS AWARDED UP TO $4,000

COMMUNITY COLLEGE STUDENTS SCHOLARSHIPS AWARDED UP TO $4,000 COMMUNITY COLLEGE STUDENTS SCHOLARSHIPS AWARDED UP TO $4,000 2015-16 CRITERIA Full-time student currently attending a community college and transferring, as a junior, to a four-year college or university

More information

Child and Youth Group. Volunteer Waiver Form

Child and Youth Group. Volunteer Waiver Form Child and Youth Group Volunteer Waiver Form VOLUNTEER WAIVER WARNING OF RISK, WAIVER, RELEASE OF ALL CLAIMS AGREEMENT Please read this form carefully and be aware that, in participating, you will be waiving

More information

CLAIM FOR LOST, STOLEN OR DESTROYED UNITED STATES SAVINGS BONDS

CLAIM FOR LOST, STOLEN OR DESTROYED UNITED STATES SAVINGS BONDS For official use only: Customer Name E Department of the Treasury Bureau of the Public Debt (Revised March 2008) Customer No. CLAIM FOR LOST, STOLEN OR DESTROYED UNITED STATES SAVINGS BONDS OMB No. 1535-0013

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

Please contact us if you have any questions. (Rev. 11/10) New York State Office of the State Comptroller Thomas P. DiNapoli

Please contact us if you have any questions. (Rev. 11/10) New York State Office of the State Comptroller Thomas P. DiNapoli New York State Office of the State Comptroller Thomas P. DiNapoli New York State and Local Retirement System Employees Retirement System Police and Fire Retirement System 110 State Street, Albany, New

More information

Compass Road to College Summer Tour Application

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

More information

Personal Medical Conditions. Obligation Regarding Own Medical Insurance. Participation In This Activity Is Voluntary.

Personal Medical Conditions. Obligation Regarding Own Medical Insurance. Participation In This Activity Is Voluntary. Personal Medical Conditions It is your responsibility to check with a medical doctor to see if you (or your ward) have any medical or physical conditions which would preclude or limit your participation

More information

Standard Field Trip Please check one Non-Standard Field Trip

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

More information

PHOTOGRAPHY/VIDEO SERVICES AGREEMENT

PHOTOGRAPHY/VIDEO SERVICES AGREEMENT PHOTOGRAPHY/VIDEO SERVICES AGREEMENT This Agreement is entered into as of the day of, 201_, between, Villanova University ( Villanova ) and, ( Photographer ). 1. Services. (a) Description and Requirements.

More information

TERMS AND CONDITIONS, RIDERS RELEASE OF LIABILITY & ASSUMPTION OF RISK INDEMNITY AND HOLD HARMLESS

TERMS AND CONDITIONS, RIDERS RELEASE OF LIABILITY & ASSUMPTION OF RISK INDEMNITY AND HOLD HARMLESS Deco Bike, LLC. 3301 NE 1 st Avenue, LPH-6 Miami, Florida TERMS AND CONDITIONS, RIDERS RELEASE OF LIABILITY & ASSUMPTION OF RISK INDEMNITY AND HOLD HARMLESS THIS IS A LEGAL AND BINDING AGREEMENT. RIDERS

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

STATEMENT OF COMPLIANCE

STATEMENT OF COMPLIANCE STATEMENT OF COMPLIANCE A. I have read and agree to comply with the CMAC Policies and Procedures. I acknowledge that the Policies and Procedures may be amended from time to time by CMAC All such amendments

More information

Registration Form Spots are limited and on a first come first serve basis

Registration Form Spots are limited and on a first come first serve basis UT Houston Medical School s JAMP Symposium March 27 th or April 17 th, 2015 Registration Form Spots are limited and on a first come first serve basis Please Note: Registration is not complete until you

More information

We are very pleased to be able to offer the 2015 parade participation fee of $150.00 for all applicants.

We are very pleased to be able to offer the 2015 parade participation fee of $150.00 for all applicants. Thank you for your interest in the Simi Valley Parade! Every September thousands of Simi Valley residents line up to view the parade of floats, cars and marching groups that are a part of our wonderful

More information

Name of Coach: Qualifications: (Attach resume) Please list qualifications and experiences relating to coaching this activity:

Name of Coach: Qualifications: (Attach resume) Please list qualifications and experiences relating to coaching this activity: University of California, Irvine Campus Recreation CLUB SPORTS VOLUNTEER COACH AGREEMENT PLEASE PRINT LEGIBLY Name of Sport Club: Year: Name of Coach: Home Address: Daytime Phone #: Cell Phone #: E-mail

More information

2016 Scholarship Program

2016 Scholarship Program 2016 Scholarship Program Purpose The purpose of WSA Scholarship Program is to provide financial awards to employees or children of employees of Wisconsin Sign Association member firms. Preference will

More information

To apply please complete application and return to: Harris Towers Attn: Volunteer Coordinator 233 Peachtree Street; Suite 1700 Atlanta, Georgia 30303

To apply please complete application and return to: Harris Towers Attn: Volunteer Coordinator 233 Peachtree Street; Suite 1700 Atlanta, Georgia 30303 To apply please complete application and return to: Harris Towers Attn: Volunteer Coordinator 233 Peachtree Street; Suite 1700 Atlanta, Georgia 30303 For more information please call 404-546-6788 Front

More information

8 th Grade Event Packet Contents

8 th Grade Event Packet Contents 8 th Grade Event Packet Contents 1) Letter Home About Upcoming Events and Donations please read and mark the appropriate box at the bottom of the page 2) Interested in Chaperoning? check the box and include

More information

West Virginia Rural Water Association

West Virginia Rural Water Association West Virginia Rural Water Association POLICY AND PROCEDURES FOR REGISTRATION AND CANCELLATION OF TRAINING CLASSES OFFERED BY THE ASSOCIATION I. Purpose The purpose of this policy is to establish specific

More information

Camp Culinaire. Camp Dates June 22-24, 2016 12:30 5:30 p.m. each day

Camp Culinaire. Camp Dates June 22-24, 2016 12:30 5:30 p.m. each day Camp Culinaire Camp Dates June 22-24, 2016 12:30 5:30 p.m. each day For more information contact Jessica Hoffman Email: jhoffman16@ivytech.edu or Phone: 317-921-4292 Ivy Tech Community College Central

More information

Earn money from you racing, from your pictures, Youtube videos and more! Only by posting on DRR Riders Group on Facebook.

Earn money from you racing, from your pictures, Youtube videos and more! Only by posting on DRR Riders Group on Facebook. Earn money from you racing, from your pictures, Youtube videos and more! Only by posting on DRR Riders Group on Facebook. Eligibility: All payouts are based on model year Current model year vs non current

More information

City of West Sacramento Department of Parks & Recreation

City of West Sacramento Department of Parks & Recreation City of West Sacramento Department of Parks & Recreation 1 Table of Contents 1. What are the core values and mission objectives of the West Sacramento Parks & Recreation Department?... 4-5 2. What is an

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

Teen Academy one week program no cost June 22 to June 26, and July 20 to July 24

Teen Academy one week program no cost June 22 to June 26, and July 20 to July 24 Teen Academy The Teen Academy is a one week program designed to give the teens of Rowlett a working knowledge of the Rowlett Police Department. There is no cost to anyone who enrolls. The classes will

More information

Independent Contractor Agreement. Name of Contractor: Address: Social Security or Tax I.D. Number:

Independent Contractor Agreement. Name of Contractor: Address: Social Security or Tax I.D. Number: HOFSTRA UNIVERSITY Name of Contractor: Address: Social Security or Tax I.D. Number: Independent Contractor Agreement THIS INDEPENDENT CONTRACTOR AGREEMENT (together with any attachments referred to below,

More information