Emergency Contact Name. Relationship: Phone: Participant's Signature (if 18 or older) :
Emergency Contact Name. Street Address: City: State: Zip: Phone Number: INDIVIDUAL HOLD HARMELSS AGREEMENT I assume all risk of bodily injury, property damage, and/or personal injury that I may incur in participating in the Xxxxxxxxx Days Festival Parade and I, for myself, my child, my heirs, executors, and administrators do hereby forever waive and release any and all claims against and agree to indemnify and hold harmless the City of Xxxxxxxxx and all their respective officers, employees, agents, representatives, successors, or assigns of any kind from any and all claims which may be made for any cause whatsoever arising as a result of or in connection with my or my child’s participation in the Xxxxxxxxx Days Festival Parade. By signing and dating this INDIVIDUAL HOLD HARMLESS AGREEMENT I acknowledge that I have read, fully understand, and agree to all of the terms of the INDIVIDUAL HOLD HARMLESS AGREEMENT and that I am authorized to do so. Signature: Date: Complete the below ONLY if the above Participant is currently under the age of 18: Name of Person Giving Consent: (Must be a parent or legal guardian of the Participant) 2nd Signature: Date: Street Address: City: State: Zip: Phone Number: Email: If you are unable to submit the INDIVIDUAL HOLD HARMLESS AGREEMENTS in advance, bring the INDIVIDUAL HOLD HARMLESS AGREEMENTS with you on parade day and present them to a designated parade official. No one in your parade entry will be allowed to participate without this form being submitted prior to the start of the parade. The City of Xxxxxxxxx reserves the right to reject or cancel any parade entry at any time should it be determined the entry detracts from the basic purpose of the Xxxxxxxxx Days Festival Parade and/or the viewing audience. Receipt of this form DOES NOT imply and/or guarantee acceptance into the Xxxxxxxxx Days Festival Parade. PLEASE SUBMIT THIS COMPLETED FORM TO:
Emergency Contact Name. Ph#: Relationship: Referral Source:
Examples of Emergency Contact Name in a sentence
Printed Name of Participant Signature of Participant Date Date of Birth Emergency Contact Name Emergency Contact Number PARENTAL / LEGAL GUARDIAN CONSENT I attest that I am the parent or legal guardian of the minor participant named above.
Signature ❑ My roommate(s): (if sending in a separate registration form) Emergency Contact: Name: Home ( ) Work ( ) I have read and agree to the Tour Conditions as stated above.
Describe way of contacting: Emergency Contact Name: Phone: GENERAL BACKGROUND Services are available to help you be safer and more independent in your household activities.
Signature Emergency Contact Name Emergency Contact Number USA Softball COVID-19 Insurance Q & A Q: We have heard rumors that softball insurance providers will not cover players if they are playing ball outside of the state while their home state is shut down.
PARENT OR LEGAL GUARDIAN: Signature Printed Name Date Emergency Contact Name and Number Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our business is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC, State, and local guidance.
More Definitions of Emergency Contact Name
Emergency Contact Name. Relationship: Home Phone: Cell Phone: Work Phone: Permission to Call: Yes No Restrictions? Please complete this information for anyone else that may participate in therapy or communicate with the therapist. Secondary Client’s Name: Relationship to Client: Date of Birth: Email: Phone: Marital Status: Single Married Partnered Widowed Divorced Polygamous Polyamorous Other Birth Sex: Female Male Intersex Choose not to disclose Gender: Female Male Non-Binary/Genderqueer Transgender Choose not to disclose Other Preferred Pronouns: She/her/hers He/him/his They/Them/Theirs Other: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Please list any additional people who will be attending the counseling session(s)- Use a second form if needed Additional Name (As needed): Relationship to Client: Date of Birth: Email: Phone: Marital Status: Single Married Partnered Widowed Divorced Polygamous Polyamorous Other Birth Sex: Female Male Intersex Choose not to disclose Gender: Female Male Non-Binary/Genderqueer Transgender Choose not to disclose Other Preferred Pronouns: She/her/hers He/him/his They/Them/Theirs Other: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Additional Name (As needed): Relationship to Client: Date of Birth: Email: Phone: Marital Status: Single Married Partnered Widowed Divorced Polygamous Polyamorous Other Birth Sex: Female Male Intersex Choose not to disclose Gender: Female Male Non-Binary/Genderqueer Transgender Choose not to disclose Other Preferred Pronouns: She/her/hers He/him/his They/Them/Theirs Other: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Additional Name (As needed): Relationship to Client: Date of Birth: Email: Phone: Marital Status: Single Married Partnered Widowed Divorced Polygamous Polyamorous Other Birth Sex: Female Male Intersex Choose not to disclose Gender: Female Male Non-Binary/Genderqueer Transgender Choose not to disclose Other Preferred Pronouns: She/her/hers He/him/his They/Them/Theirs Other: Race: White Black/African American Asian Latinx/Hispanic Native American/Indigenous Multi-racial Other Choose not to disclose Additional Name (As needed): Relationship to Client: Date of Birth: Email: Phone: Marital Status: Single Married Partnered Widowed Divorced Polygamous Polyamorous Other Birth Sex...
Emergency Contact Name. Phone: I would like to receive an update while boarding: □ by email □ by text □ emergency only MEDICATIONS: $1.30 / dose / day each Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting Administer once / twice daily in AM / PM starting DIET: Please indicate amounts for each meal and frequency given. *Please let us know if your cat needs to be fed once they are checked in by our staff* Canned food: Dry food: Treats: TREATMENT: Please list any services that you would like to have done during your cat’s stay. (Additional fees apply.) □ Brush sessions □ Playtime sessions □ Nail trim □ Other (list below) If an exam is performed, please have the doctor contact □ call me □ email me □ text me, or □ I prefer to wait and discuss exam findings at pick up. Personal Items:
Emergency Contact Name. Physical Address: City: Postal Code: Relationship to Child: Home Phone Number: Cell Phone Number: Place of Work: Work Address: Work Phone Number:
Emergency Contact Name. Physical Address: City: Postal Code: Relationship to Child: Home Phone Number: Cell Phone Number: Place of Work: Work Address: Work Phone Number: Authorized Person(s) other than the parent/guardian(s) to whom child may be released: Name: Phone Number: Alternate Phone Number: Name: Phone Number: Alternate Phone Number: Name: Phone Number: Alternate Phone Number: Person(s) to whom child may NOT be released. Name(s), description. Are there any legal custodial issues? YES NO If yes, please explain and supply relevant legal documents. If yes, please refer to Parenting Order Acknowledgement. I, , acknowledge that, should there be a parenting order in place regarding my child , it is my responsibility to provide a copy of this order to the YMCA Before & After School Care Program. I also understand that I am responsible for providing any updates to this order should any changes occur. If I do not provide a copy of this parenting order, I understand that my child will be allowed to leave the program in the company of any parent/ guardian listed within their file. The YMCA Before & After School Care Program will not undertake any responsibility for the child upon releasing the child to a parent/ guardian in accordance with program procedures and licensing regulations. Staff Use Only: Was a parenting order provided? Staff Initials: YES NO Parent/Guardian Signature: Parent/Guardian Signature: Date: Date: Grade: ALL ABOUT ME Names and ages of other children in your family: 1: 3:
Emergency Contact Name. Phone: Address: City: State Zip Applicant’s Income/Credit: Include all sources of income you want considered Place of Employment: How many hours per week: Address: City: State: Zip: How long? From: To: Gross Monthly Income: Phone#:
Emergency Contact Name. Relation: Address: City/State/ZIP Telephone: Cell Phone: Email: Exhibit "B" HOLD HARMLESS" AGREEMENT I, , whose address is (hereinafter the "Vendor"), in consideration of being provided selling space at the Venice Farmers Market agree to the following terms and conditions:
Emergency Contact Name. Phone: Guardian/Legal Representative: (If applicable) First Last Phone: E-mail: (Optional) Billing Information (if xxxx is to be sent to a different location than address listed above): Name: Address: Phone: __ E-mail: (Optional) Start Date of Services: / / Direct support workers hours up to per month/week Night Support hours up to /month Case Management/Service Coordination up to /month Skills Training up to /month Please note: If you exceed the stated amount of units, your signature on the timesheet(s) serves as authorization. You will be invoiced for all hours recorded on the signed timesheet. Fees: Deposit and Billing Information Initial Assessment Fee: $50.00 (non-refundable) Direct Support Worker (DSW) Services : $15.00/hour Night Support: $50.00/night (one night equals 8 hours) Case Management/Service Coordination: $50.00/hour Skills Training: $35.00/hour FMS Fee: $160.00/ month Timesheets are provided to record services. PILR, Inc. processes timesheets twice a month. For the pay period the 1st thru the 15th timesheets are due by 18th of the month and for the pay period the 16th thru the end of the month timesheets are due by the 3rd for the following month. The direct support workers are paid on the 15th and the last day of each month. You (or your legal representative) must sign each timesheet & send it to PILR, Inc. (You may also fax timesheets to 000-000-0000 or you may email them to: XXX@xxxx.xxx). Please see back of PILR, Inc timesheet for additional information. PILR, Inc FMS requires prior payment for the direct and night support services. An invoice for payment will be mailed to you monthly. You are responsible for remitting payment directly to PILR, Inc. (Individuals with private insurance should refer to insurance contract addendum.) Payment is due within 10 days of receipt of your invoice in order to continue services. Payment I understand: (Initial each item) I maintain the right to amend this contract at any time; I maintain the right to terminate a DSW at any time and agree to contact PILR, Inc. within 48 hours of doing so; I maintain the right to cancel this contract and will provide PILR, Inc. a minimum of 10 business days notice prior to cancellation; If I discontinue services and choose to privately pay DSWs referred to me by PILR, Inc. I agree to pay PILR, Inc. a referral fee equal to $150.00 per services at DSW; PILR, Inc. reserves the right to terminate our financial management any time. Assessment Fee Date Amount S...