Guardian Signature. Assignment of Benefits/Financial Agreement I hereby give authorization for payment of insurance benefits to be made directly to the Advanced Pain Institute and my assisting physicians for services rendered. I understand that I am financially responsible for all charges, whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits.
Guardian Signature. I agree that a photocopy of this agreement shall be as valid as the original. Patient/Guardian Signature Witness Signature
Guardian Signature. There is a $275 registration fee per child for securing a spot at Xxxxxx Xxxx Catholic Parish School. This is a non-refundable deposit. Please make check payable to Xxxxxx Xxxx Parish.
Guardian Signature. (Please sign after reviewing that the above homework is complete and all homework pages have been initialed) o Instructor Signature: o The student has completed all assignments required. A certificate of completion can be granted. Homework Assignment #1
Guardian Signature. Website Consent Do we have your consent for us to put your child’s picture on our website (xxxxxxxxxxxxxx.xxx/xxxxxxxxx) and our Facebook page? We will be showing pictures of our activities each month. Their names and addresses would not be listed. Yes □ No □ Parent/Guardian Signature: Agreements
Guardian Signature. As a user of the Lavaca Public Schools’ computer network, I hereby agree to comply with the stated rules-communicating over the network in a responsible fashion while honoring all relevant laws and restrictions. Student Signature: Student Electronic Device & Internet Use Agreement found on page 30-33 AGREE DO NOT AGREE Please initial the items to indicate that you “agree” or “do not agree” to each item listed and sign below. To allow publication of directory information to all public sources. This would permit the release of directory information for active and inactive students to the Military, postsecondary institutions, potential employers and all public sources such as newspapers. Student’s name and/or picture to be used in yearbook, website, photo, video, district social media or newspaper. Student to access the xxxxxxxxxxxxx.xxx email account at LHS The Student Handbook is available on our district website for your convenience. You may access the handbook by going to the district home page at xxxxx://xxx.xxxxxxxxxxxxx.xxx. Select your child’s school, Student Information, and the handbook icon. Please read through the handbook with your student so that you both are familiar with our policies. Your signature, as well as your student’s signature, is required on this form to indicate that you have been given access to the handbook. If you do not have access to the internet, or for any reason need a printed copy of the handbook, please call a school office (numbers below). A copy will be sent home with your student that day. Lavaca Elementary School 479)-674-5613 Lavaca Middle School 000-000-0000 Lavaca High School 000-000-0000 This certifies that we (parent/guardian and student) have received instructions to access the student handbook including but not limited to the discipline, attendance, computer use, and chemical screen testing policies as well as Parent Involvement Summaries, Smart Core Curriculum, and Graduation requirements of Lavaca Public Schools as outlined by Act 104 of the 1983 1st Extraordinary Session of the General Assembly of the State of the State of Arkansas and polices of the Lavaca Board of Education. The law states this form must be signed by parent and student and returned to the school to be kept in the principal’s office. Parent Signature Student Signature Date Xxxxx Xxxxxx, Secretary Xxxxxx Xxx Xxxxxx Xxxx Xxxxx Xxxxxx, President Xxxxxx Xxxxxxxx Mr. Xxxxx Xxxx Xx. Xxx Xxxxx Xx. Xxxxx Xxxxxxx Xxx. Xxxxxxx Xxxx Superintendent Elem...
Guardian Signature. Date: / / ▪ Children attending Pre School can choose to attend until the day before their sixth birthday as long as they are NOT enrolled at any school. I wish for my child to attend Methven Pre School until date. I am signing to say that they are not enrolled at any school while attending this centre. Parent/Guardian signature: Statutory Holidays: This enrolment agreement is inclusive of school term breaks. Methven Pre School is closed for all of the following statutory holidays and for two weeks over the Christmas/New Year period, (dates advised annually) Waitangi Day Good Friday Easter Monday Anzac Day Queen’s Birthday Labour Day Canterbury Anniversary Day Christmas Day Boxing Day New Year’s Day 2nd January Parent Declaration: I have read and understand the terms and conditions of enrolment as set out above. I declare that all the above information is true and correct to the best of my knowledge and understand that Methven Pre School will accept children whose parents/caregivers undertake to abide by the policies and procedures of the centre and Ministry of Education Licensing Criteria. Parent/Guardian Signature: Date: / / Date: / / Service Provider Signature: On behalf of Methven Pre School Learning and Child Care Centre, I declare that this form has been checked and all relevant sections have been completed. Service declaration: ANY CHANGES TO THIS FORM MUST BE SIGNED & DATED BY PARENT/GUARDIAN
