Licensed Providers. Each physician engaged by the Medical Group to provide services at the Office shall be duly licensed to practice medicine in the State of California and shall be board certified or board eligible in the specialty of radiology and shall maintain professional liability insurance in minimum amounts of $1,000,000/$3,000,000 per annum.
Licensed Providers. Do you receive funding from any other source for this child? Check all that apply: School Readiness State Head Start Federal Head Start DSS CDC DSS BAS Relative and In-Home Providers: Are you related to this child? Yes No If related, specify your relationship below: Grandparent/Great Grandparent Aunt/Uncle Sibling Niece/Nephew First Cousin/Second Cousin Other: CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM
Licensed Providers. Do you receive funding from any other source for this child? Check all that apply: School Readiness State Head Start Federal Head Start DSS CDC DSS BAS CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). Is the schedule the same each week? Yes No If no, explain how the schedule varies: ► Section 3: Children In Care (Complete for each child needing Care 4 Kids assistance.) CHILD 2 - Full Name: Date of Birth: Date care started: How much do you charge the parent per week? $ Do you provide care for this child before or after school? (Check boxes) Before School After School
Licensed Providers. Do you receive funding from any other source for this child? Check all that apply: School Readiness State Head Start Federal Head Start DSS CDC DSS BAS CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). Is the schedule the same each week? Yes No If no, explain how the schedule varies: ► Section 4: Provider Certification: (To be Completed by the Child Care Provider.) To the best of my knowledge, I certify that:
Licensed Providers. To the knowledge of the Loan Parties, each Licensed Provider holds all professional licenses and other Material Health Care Permits required in the performance of such Licensed Provider’s duties for the Loan Party, Subsidiary or Managed Entity, and, each such Health Care Permit is in full force and effect. To the knowledge of the Loan Parties, no suspension, revocation, termination, impairment, modification or nonrenewal of any such Health Care Permit is pending or threatened in writing.
Licensed Providers. Do you receive funding from any other source for this child? Check all that apply: ❑ School Readiness ❑ State Head Start ❑ Federal Head Start ❑ DSS CDC ❑ DSS BAS
Licensed Providers. Do you receive funding from any other source for this child? Check all that apply: School Readiness State Head Start Federal Head Start DSS CDC DSS BAS Relative and In-Home Providers: Are you related to this child? Yes No If related, specify your relationship below: Grandparent/Great Grandparent Aunt/Uncle Sibling Niece/Nephew Cousin/Second Cousin Other: CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM Is the schedule the same each week? Yes No If no, explain how the schedule varies: CHILD 2 - Full Name Date of Birth Date care started How much do you charge the parent per week? $ _ Do you provide care for this child before or after school? (Check boxes) Before School After School
Licensed Providers. Each physician engaged by the P.C. to provide services at the Office shall be duly licensed to practice medicine in the Commonwealth of Massachusetts and shall be board certified or board eligible in the specialty of radiology and shall maintain professional liability insurance in minimum amounts of $1,000,000/$3,000,000 per annum.
Licensed Providers. Each Physician engaged by Medical Group to provide services at the Licensed Premises shall be duly licensed, without restriction, to practice medicine in the State of Washington, shall be board certified or board eligible in the Medical Specialty; shall maintain professional liability insurance in minimum amounts of $l,000,000.00/$3,000,000.00 annual aggregate; and shall have never been convicted of a criminal offense related to healthcare, or been listed by any federal or state healthcare program as excluded or otherwise ineligible to participate in such federal or state program.
Licensed Providers. Each Leased Personnel shall be duly licensed to practice medicine in the State of New Jersey and shall be board certified or board eligible in the specialty of radiation oncology and shall maintain professional liability insurance in minimum amounts of $1,000,000/$3,000,000 per annum.
