Primary Language. Our EMT Basic course is promoted and administered in the English language. If English is not the student's primary language, and the student is unable to understand the terms and conditions of the enrollment agreement, the student shall have the right to obtain a clear explanation of the terms and conditions and all cancellation and refund policies in his or her primary language and will have an appointment with the Compliance Officer prior to the 7 day cancellation period. Student INITIALS here for English Language: . Student INITIALS here for Non-English Language: .
Primary Language. The language identified by the end user as the language that will be required for communication. This is also referred to as the preferred language.
Primary Language. Was the client adopted? Yes No Is the client a student? Yes No Ethnicity: Lived at any time in xxxxxx care? Yes No Name of School/College Part-Time Student Full-Time Student Highest grade/education/degree completed Marital Status: Never Married Widowed Married Common Law Separated Divorced Engaged Partners Spouse/Partner’s Name: Soc. Sec. #: (Last) (First) (Middle Initial) Gender: M F Age: Birth date: Length of Relationship: Work # Home # Cell # If separated: Address, City, State & Zip Occupation of Spouse Employer: Employer Phone # ( ) Check One: Employed Full-Time Employed Part-Time Unemployed Employer Address _ City, State, Zip: How long working for the current employer? What is their gross income? (We may need this income to set your fee) Children and/or dependents currently at home & their ages: Referred By? How Did You Hear About Us? (Check all that apply): I am a former client returning. How long ago? Family or Friend A client Brochure/Flyers Internet Yellow Pages Employee Assistance Program Employer/Supervisor Colleague Union Representative Insurance Company/Managed Care Court/Legal School Physician Probation Another Therapist Minister/Priest/Rabbi Word of mouth Other PLEASE SIGN BELOW TO INDICATE THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT: Signature of Client Date Signature of Parent/Legal Guardian/Xxxxxx Parent/Conservator/Other Date (Required if participant is a minor, under age 18) INSURANCE INFORMATION Who Is Responsible for this account? Who is the insured? What are your insurance requirements? Primary Insurance Insured is: Self Spouse/Partner Child Other What is the insurance company name? Billing Address Phone Number ( ) Is it a PPO? [ ] or HMO? [ ] Membership/Benefit Policy Number Group # Plan # Effective Date: / / How much coverage do you have in a year? Have you met your deductible? Yes No What are your insurance company’s credential requirements for pursuing counseling? (e.g. licensed MFT, registered social worker, etc.) Secondary Insurance: Insured is: Self Spouse/Partner Child Other What is the insurance company name? Billing Address Phone Number ( ) Is it a PPO? [ ] or HMO? [ ] Membership/Benefit Policy Number Group # Plan # Effective Date: / / How much coverage do you have in a year? Have you met your deductible? Yes No Whatareyourinsurancecompany’scredentialrequirementsforpursuingcounseling?(e.g.licensedMFT Social worker.)
Primary Language. Our course is promoted and administered in the English language. If English is not the student's primary language, and the student is unable to understand the terms and conditions of the enrollment agreement, the student shall have the right to obtain a clear explanation of the terms and conditions and all cancellation and refund policies in his or her primary language and will have an appointment with the Compliance Officer prior to the 7 day cancellation period. Student INITIALS here for English Language: . Student INITIALS here for Non‐English Language: .
Primary Language. You have the right to receive information in your primary language. You have the right to request an interpreter in your primary language, including American Sign Language (ASL). If you have a disability, you have the right to receive information in alternative formats such as, Large Print, Braille, etc. You may request the agencies provide an interpreter for meetings and/or written documents in your primary language or in an alternative format.
Primary Language. English is the primary language of this UA, of MOTI and of Sophia. The use of any other language is purely for your convenience, and, in the event of conflict, the English versions shall take precedence.
