PLEASE ANSWER THE FOLLOWING QUESTIONS a. During the previous twelve (12) months, have you entered into contracts, including the present contract, bid or proposal, with the City of Berkeley for a cumulative amount of $100,000.00 or more? YES NO If no, this Contract is NOT subject to the requirements of the LWO, and you may continue to Section II. If yes, please continue to question 2(b).
PLEASE ANSWER THE FOLLOWING QUESTIONS. Does your child take any Foreign language courses in Grades 6, 7 or 8? If yes, please check off one or more of the following two language selections. Does your child take band or chorus in Grades 6-8? Yes French Yes No Spanish No If yes, please check off one or both of the following two course selection. Does your child participate in athletics? (for Grades 6-12) Band Yes Chorus No ***For Students Who Participate in Sports*** NEWARK CENTRAL SCHOOL DISTRICT ATHLETIC DEPARTMENT FORM FOR GRADES 7-12 FAX # 000-0000 Previous School Attended: Student’s address while attending the above school Street and Number City, State, Zip With whom did student reside at this address? Father Mother Guardian 000 XXXX XXXXXX XXXXXX NEWARK, NEW YORK 14513 (000) 000-0000 FAX (000) 000-0000 Date: XXXXXXX X. XXXX NEWARK CENTRAL SCHOOL DISTRICT Superintendent of Schools XXXXXX X. XXXXX Assistant Superintendent Curriculum & Instruction XXXXXX X. XXXX Assistant Superintendent Business XXXXX XXXXXX Director of Pupil Services NEWARK CENTRAL SCHOOL DISTRICT REGISTRATION FORM AUTHORIZATION FOR RELEASE OF INFORMATION I hereby request that Newark Central School receive a transcript of the health/immunizations and scholastic records for my son/daughter from: NAME OF PREVIOUS SCHOOL: ADDRESS: PHONE: ( ) FAX: ( ) STUDENT NAME: GRADE: D.O.B.: SIGNATURE OF PARENT/GUARDIAN: ** These records should include ** ** P☜LEASE SIGN ** ⮚Transcripts of grades (including grades in progress up to the date of withdrawal*) *Please provide numerical equivalent if alphabetical grades are reported* ⮚Test scores, including Competency Test Scores/State Assessments ⮚Health/Immunization Information ⮚Guidance Information, Special Education, 504 Records ⮚Evaluation Reports (Psychological, Related Services, etc.) ⮚AIS Records ⮚Instructional Support Team Interventions and Notes ⮚ ESL Service Records Newark Senior High School – Grades 9 – 12 Attn: XxxxXxxx Xxxxxxxxx, Building Secretary 000 Xxxxxxx Xxxxxx, Newark, NY 14513 Tel: (000) 000-0000; Fax: (000) 000-0000 Newark Middle School – Grades 6 – 8 Attn: Xxxxx Xxxx, Building Secretary 000 Xxxxxxx Xxxxxx, Newark, NY 14513 Tel: (000) 000-0000; Fax: (000) 000-0000 X. X. Xxxxxx Intermediate School – Grades 3 – 5 Attn: Xxxx Xxxxx, Building Secretary 000 Xxxx Xxxxxx Xxxxxx, Newark, NY 14513 Tel: (000) 000-0000; Fax: (000) 000-0000 Xxxxxxx School – Grades K-2 Attn: Xxxxxx Xxxxxxx, Building Secretary 000 Xxxx Xxxxx Xxxxxx, Xxxxxx, XX 00000 Tel: (000) 000-0000; Fax: (000) 000-0000...
PLEASE ANSWER THE FOLLOWING QUESTIONS. 1. Do you have a Doing Business As (DBA) account? If so, please provide the Legal and DBA names. Legal Name DBA
PLEASE ANSWER THE FOLLOWING QUESTIONS. Your answers will be held in the strictest of confidence. (Circle one) Yes No 1. Do you currently use illegal drugs? Yes No 2. Have you ever been convicted of the illegal manufacture, sale or Possesion of drugs? Yes No 3. Have you ever been convicted of a criminal offense? (Conviction of a crime is not an automatic bar to employment. Lords of Soccer will consider the nature of the offense, the date, and the relationship between the offense and the position applied for.) Yes No 4. Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? Yes No 5. Are you subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection? I understand that the Lords of Soccer camps may deny employment to any person who answers any of the above questions, numbered 1-5,
PLEASE ANSWER THE FOLLOWING QUESTIONS. If yes to any of the following questions, please attach a detailed information sheet Have you ever had a state license or certification to practice your profession relinquished, denied, limited, revoked or suspended, either voluntarily or involuntarily? YES NO Have any investigations or disciplinary actions ever been initiated and/or are any now pending against you by a state license board, certification agency or professional organization? YES NO Have you ever been convicted of a felony or misdemeanor relating to the practice of your profession, other health care related matters, third-party reimbursement, violence, controlled substance violation, or anything other than a minor traffic violation? YES NO Have you ever had hospital privileges denied, revoked, suspended, or voluntarily surrendered? YES NO Have you ever had disciplinary action or been denied membership/renewal in any professional society organization? YES NO Have you ever been the subject of investigation by or been suspended, sanctioned, or otherwise restricted from participating in any private, federal or state health insurance program (ie: Medicare or Medicaid)? YES NO If yes to any of the following questions, please attach a detailed information sheet. Please include name of court in which suit was filed, caption and docket number of case, name and address of attorney defending you, and any other relevant details. Have you ever been named as a defendant in any criminal proceeding? YES NO Has your professional liability insurance ever been terminated by action of an insurance company? YES NO If yes, state when and by what company. Have you ever been denied professional liability coverage? YES NO If yes, state when and by which company. Have you ever been rated in a higher than average risk class for your profession, or had an additional premium imposed upon you because of your claims history? YES NO Have any professional liability suits been filed against you? YES NO Have any professional liability suits been filed against you of which are presently pending? YES NO Have any judgments been made against you in a professional liability case/claim, or have you entered into any settlements? YES NO If yes to any of the following questions, please include a sheet of detailed information. Are you able to perform all physical and mental functions, with or without accommodation, necessary to provide patient care services for which you are seeking clinical privileges? YES NO If no, please explain. Ar...
PLEASE ANSWER THE FOLLOWING QUESTIONS. 1. Are you under indictment or information (an information is a formal accusation of a crime made by a prosecuting attorney) in any court for a crime for which a judge could imprison you for more than one (1) year? YES □ NO □
