PLEASE PRINT ALL INFORMATION Sample Clauses

PLEASE PRINT ALL INFORMATION. If you are a minor (0-17 years of age), legal guardian’s information will be required Patient Name (Last, First, MI) Patient ID# Last 4 Digits of SSN U.S. CITIZEN  Yes  No Date of Birth Number of Dependents (other than self & co-applicant) Ages of Dependents Primary Contact - Phone ( ) Street Address (Do Not Provide PO Box) City State County ZIP Code  Permanent Address  Temporary Address Current Xxxxxxxx Xxxxxx Xxxxxxx, Xxxx, Xxxxx Position If you are not working, how long have you been unemployed?

PLEASE PRINT ALL INFORMATION. Gr. 2021-22 Name: ❑ Male ❑ Female 9 10 11 12 Last First Middle Circle Gr. 2021-22 Name: ❑ Male ❑ Female 9 10 11 12 Last First Middle Circle Father’s Name: Home Address: City/Zip: Home Phone: Cell Phone: Preferred E-Mail: Place of Employment: Occupation: Work Phone: Mother’s Name: Home Address: City/Zip: Home Phone: Cell Phone: Preferred E-Mail: Place of Employment: Occupation: Work Phone: E-Mail to Receive Statements: PLEASE SELECT ONE OF THE PAYMENT OPTIONS ON THE ATTACHED AGREEMENT, SIGN AND COPY THE AGREEMENT; RETURN THE ORIGINAL TO ST. XXXXXX XXXXXXX.

PLEASE PRINT ALL INFORMATION. ANSWER ALL QUESTIONS. Attach separate sheets if necessary. TYPE EXCEPT FOR SIGNATURE [Attach additional sheets if required]

PLEASE PRINT ALL INFORMATION. Child’s Name: I Give permission for videos and/or photos of my child to be posted on the Junction City District website. I Do Not Give permission for videos and/or photos of my child to be posted on the Junction City District website Parent’s Signature: Date: Grade: Homeroom Teacher: Junction City School Cafeteria Breakfast/Lunch Prices 2018-2019 Breakfast (Students K-12) $1.00 Breakfast (Adults) $2.25 Breakfast (Reduced) $0.30 Lunch (Students K-6) $1.75 Lunch (Students 7-12) $2.00 Lunch (Teachers & Adults) $3.75 Lunch (Reduced) $0.40 Dear Parent/Guardian: During the school year we will have our share of viruses, cold and other illnesses. These are spread very easily. For the protection of all our children, please remember: