Date of Birth means the subject’s date of birth using MMDDCCYY format as indicated in Exhibit A.
Date of Birth. Age: Grade: Emergency contact: Date(s) of safety instruction: Number of credit hours to be granted: Concurrent, related academic course*: *For a student in a state-approved CTE program, the above verification must be made by a vocationally-certificated teacher or coordinator. Type of Placement (check one): Non-CTE Work-Based CTE Work-Based Learning (Program Serial Number __________________) Paid or Unpaid Work-Based Paid or Capstone In-District (gr. 11&12 only) Special Education Work-Based Unpaid Less-Than-Class-Size Employer Information (Complete for external placements only – Paid or Unpaid) Name of Firm: Supervisor: Address: Phone: City: Zip: Worker’s Disability Carrier: Policy No. Liability Insurance Carrier: Policy No. Job Title: Date Employment Begins: Ends: Hours to be worked: Mon Tue Wed Thu Fri Sat Sun Earliest Latest Avg. Hrs. Per Day*: Xxx Xxx. Per Week**: Starting Wage: *Cannot compute to more than ½ of the pupil’s FTE. **Work and school hours cannot exceed 48 hours per week for students under age 18 Unpaid Employment Information (Complete for in-district placements only) IMPORTANT: IN-DISTRICT placements MUST be directly related to one of the following: State-Approved CTE work-based (Name of related CTE Program: ) PSN from above: Postsecondary career and employment goals and objectives in the pupil’s transition service plan developed for special education services. A copy of the pupil’s transition services plan must be attached and relate directly to placement. Failure to do so will result in lost FTE. Position/Assignment: Supervisor: Beginning Date: Ending Date: This assignment is: (check one) for the marking period for the semester for the school year Hours to be worked (must occur during scheduled classroom time): Mon Tue Wed Thu Fri Education Goals Education/Career Goal(s): List the education goals related to this placement that align with the student’s career pathway contained in the student’s educational development plan. For unpaid work-based experiences, specific, unduplicated skills must be listed for each 45 hours of placement. ___________________________________________________________________________________________________________________ *Attach copy of the EDP or IEP.
Date of Birth means the month, day, and year on which the patient whose hospitalization is being recorded was born.
Examples of Date of Birth in a sentence
The Collaborator agrees that Xxxx may report and disclose any transfer of value or payment from Xxxx to the Collaborator for the Services, including but not limited to fees, travel expenses, meals, etc., including the Collaborator’s personal data (details such as full name, personal and institution address, Licence number, Tax ID, email address, mobile phone number and Date of Birth) as required under Transparency Regulations, both during the term of this Agreement and after expiry of this Agreement.
Required fields include the Surname of Covered Individual, First Initial, Date of Birth, Sex code, a DCN assigned by the VDSA partner, Transaction Type, Coverage Type, Individual’s SSN, Effective Date, and Termination Date.
Patient Information: Patient Name: ______________________________________ Date of Birth: ______________ Address:___________________________ City__________________ State: _______ Zip: ________ Home Number: __________________________ Mobile Number: __________________________ Cardholder Information: Please indicate the name and address associated with the credit or debit card you wish to use.
This can include but is not limited to: your First name and Last name, Email address, Phone number, Cookies and Usage Data, Social Security Number, Date of Birth, Banking Information, Financial Account Numbers and/ or Balances, Transactions, Sources of Income.
More Definitions of Date of Birth
Date of Birth. SSN: Date: We ask that you update this information annually, or as circumstances change. Thank You Updated: Initials/Date Initials/Date Initials/Date ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE By signing below, I am acknowledging that I am aware of the HIPAA Privacy Act. I also acknowledge that I have been offered a copy of the Mid-Atlantic Women’s Care Privacy Notice pursuant to the Federal regulations known as the HIPAA Privacy Rule. If I am unaware of this, a copy shall be provided to me. Patient Signature Patient PRINTED Name Date MARKETING AUTHORIZATION FORM Patient Name: Date: _
Date of Birth. Month: Day: Year: __ Home Phone: Cell Phone: Work Phone:__ ________ E-mail: Organization/Group/Club (if applicable) _ _ Special Needs Emergency Contact: Name: Phone:
Date of Birth. SPA Type: Guaranteed Performance-Based This Standard Player Agreement (this “SPA”) is made as of the Effective Date by and between the Player and the Club (each a “Party” and, collectively, the “Parties”). In consideration for the mutual promises contained herein, the Parties agree as follows:
Date of Birth. Email: Participant's Signature (only if age 18 or over): Date: Parent/Guardian Signature (if under age 18): Date:
Date of Birth. Age: Gender: M F Child’s T-shirt Size: Youth: S M L XL Adult: S M You must have a completed and turned in an emergency information packet before you will be considered registered. Payment Agreement ● A $50.00 deposit is required per child per camp. Deposits are not refundable or transferable. ● Day Camp: Each camp will be held with a $50.00 non-refundable deposit for each camper per weekly session, at time of registration to hold the spot. Deposits are applied toward the cost of each session. ● Cancellations/Refunds/Credits: Refunds or credits for camp are available only with a doctor’s note explaining injury or inability to attend YMCA camp due to illness, accident or injury. The $50.00 deposit for each child per camp, will not be refunded or credited. There is a $25.00 fee due for all NSF checks and that payment must be made within 24 hours in order for your child to attend camp. ● Each camp will be drafted from your checking or savings or credit card, please see the Summer Camp Billing form to see camp draft dates. ● All camps must be paid in full the Wednesday prior to the start of camp. If payment is not received in full after the above date, you will be charged a $15.00 late fee. ● Cancellations/Refunds/Credits: Refunds or credits for a camp are available two weeks prior to the first week of camp only! However, the deposit of $50.00 per week for the day camps is a NON-REFUNDABLE deposit and non-transferable. ● If you wish to change camp weeks, you will be asked to pay a deposit for the camp you are changing into. There will be no option to switch or transfer camps after the Wednesday of the week prior to camp, in order to maintain staff/camper ratios needed for safety. ● All campers must hold a valid YMCA membership to receive the member rate and must remain valid until Sept. 1, 2019. If you register as a non-member we will not change the camp registration rate if you later become a member. ● Families that have applied for Action for Children and/or approved by Action for Children need to pay the estimated co-pay to be accepted into the program. Action for Children coverage does not hold your child’s spot. Families that have applied for Action for Children are responsible for all camp payments until they are approved. ● Action for children does not cover all costs of camp-the remaining balance is the parent’s responsibility. I have read and understand the above statements. I fully understand my responsibility for payment of summer camp for any regist...
Date of Birth. Age: Sex: □ Non- Binary □ Male □ Female Does the patient live or work in a congregate setting (e.g., long-term care facility, shelter, group home, prison) □ YES □ NO Patient Clinical Information Date of symptom onset: Symptoms Observed: □ None Does the patient have any underlying conditions? □ Fever □ None □ Immunocompromised □ Tiredness □ Runny nose □ Unknown □ Pregnant □ Dry Cough □ Loss of smell □ Diabetes □ Chronic Lung Disease □ Body Ache □ Diarrhea □ Hypertension □ Chronic Liver Disease □ Nasal Congestion □ Loss of Appetite □ Cardiac Disease □ Chronic Kidney Disease LABORATORY TESTING – Completed by Patient □ Other Has the patient received the COVID-19 Vaccine? □ Yes □ No Which COVID-19 Vaccine has the patient received? □ Moderna □ Pfizer □ Xxxxxxx & Xxxxxxx vaccine INSURANCE INFORMATION: CARRIER NAME: GROUP: ID: □ CASH ONLY – BILL TO CLIENT I hereby acknowledge and give full and complete consent for testing and request: □ RT-PCR COVID Swab Test □ SARS-Cov2 IgG Antibody Test □ SARS-Cov2 IgM Antibody Test □ Influenza A/B PCR SOURCE of RT-PCR Swab Test: □ Anterior Nares Swab (Nostril) □ Nasopharyngeal Swab (Nasal) □ Oropharyngeal Swab (Throat)
Date of Birth. Age: Sex: Relationship: Cell Phone: Home Phone: Work Phone: Name: WHO TO CONTACT IN CASE OF EMERGENCY Join our mailing list to receive news on special events and promotions! Email: MEDICAL HISTORY Do you have any medical conditions for which you are currently receiving treatment or taking any medication? Yes No If yes, explain: Do you have any pre-existing medical conditions? Yes No If yes, explain: Do you carry any medical insurance? Yes No If so, insurance company/provider: I understand that my use of the services provided by Carabiner’s Indoor Climbing, their agents, owners, officers, employ- ees, volunteers, participants and any other persons or entities acting on their behalf, hereafter known as “CIC,” is entirely volun- tarily and with a complete and full understanding that any and all such usage, including, but not limited to climbing, is entirely voluntary and with a complete and full understanding that any and all such usage involves all manner of hazards and dangers. I acknowledge and agree that I have a personal responsibility to know and understand the safety rules administered by CIC. I have received full information, inspected the premises and have had any questions answered to my full satisfaction. I am responsible for checking, ensuring and maintaining the safety and safe operating condition of any and all equipment, gear, or apparel (including, but not limited to, anchors, ropes, carabiners, belay devices, harnesses and/or shoes) that I may utilize while present in CIC regardless of where or from whom I may have obtained such equipment, gear, or apparel. I use and accept those items “as is” and use them at MY OWN RISK. Participant’s Signature: Date: Parent’s Signature: (If participant is under 18) Date: