RESPONSIBILITY AGREEMENT. A Responsibility Agreement, contained herein as Appendix C, separate from the teacher's contract, shall be entered into by the Board and the teacher elected to department head or extra or co-curricular positions for which compensation is provided. Payments for Responsibility Agreements shall be included with the teacher's salary check. Upon written request a teacher may elect to receive payment under the following options:
RESPONSIBILITY AGREEMENT. It is agreed the parent and/or contractor shall assume full responsibility for the proper and safe transportation of all student(s) affected by this contract and that the Prior Lake-Savage Area School District shall be obligated only to make the payments provided for in this contract. The contractor further agrees to hold the Prior Lake-Savage Area School District harmless from any and all claims that may arise from the transportation of the student(s) as provided herein, to pay any judgments which may be obtained against the Prior Lake-Savage Area School District as a result thereof, and to indemnify the Prior Lake-Savage Area School District for all expenses incurred in defending itself against any such claim. INDEPENDENT SCHOOL DISTRICT 719 0000 Xxxxx Xx Prior Lake, MN 55372 By: Date: By: Date: School District Parent/Contractor School District Use Only:
RESPONSIBILITY AGREEMENT. Resident understands and agrees that as a condition to the privilege of using the foregoing facility (ies), the resident shall be responsible for any and all costs, loss or damage (including, without limitations, reasonable attorney’s fees and any loss of use of items being repaired or replaced) to the foregoing facilities and any fixtures, furniture, equipment and personal property and/or inventory located therein, which cost, loss or damage results from the acts or omission of the resident or any guest or invitee of resident. Additionally, the resident hereby agrees to release, indemnify and hold harmless The Sulgrave Regency Condominium Association and its employees from any and all claims, losses, liability, costs, (including reasonable attorney’s fees) resulting from or arising out of or related to the use of the above facility(ies) by resident or its guests or invitees. Resident (Signature) Resident (Print name) Condo Address The undersigned hereby consents to the use of the foregoing amenities by the homeowner for the time periods stated and subject to the term of this agreement. Sulgrave Regency Condominium Association BY:
RESPONSIBILITY AGREEMENT. It is agreed the parent and/or contractor shall assume full responsibility for the proper and safe transportation of all student(s) affected by this contract and that the Burnsville-Xxxxx-Xxxxxx School District shall be obligated only to make the payments provided for in this contract. The contractor further agrees to hold the Burnsville-Xxxxx-Xxxxxx School District harmless from any and all claims that may arise from the transportation of the student(s) as provided herein, to pay any judgments which may be obtained against the Burnsville-Xxxxx-Xxxxxx School District as a result thereof, and to indemnify the Burnsville-Xxxxx-Xxxxxx School District for all expenses incurred in defending itself against any such claim. Approved By (Contractor/Parent Signature): Date: District Approval: Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ School District Use Only:
RESPONSIBILITY AGREEMENT. This statement of responsibility shall serve as an agreement between the SC Bar Law Related Education Division and the individual selected to participate in the Bar’s training session on We the People as indicated above on the selected date. SC Bar Law Related Education Division Responsibilities: Provide complimentary lunch. Provide one classroom set of We the People materials for thirty students. Provide training and implementation guidelines for the We the People program. Participant Responsibilities: Attend training session in Columbia, SC. Teach We the People to at least one class in the 2019-2020 school year. Mail, fax, or email completed form no later than July 22, 2019 to: SC Bar: Law Related Education Division Post Office Box 608, Columbia, SC 00000-0000 Phone: (000) 000-0000 Fax: (000) 000-0000 Xxxxxx Xxxx xxxxx@xxxxx.xxx
RESPONSIBILITY AGREEMENT. This statement of responsibility shall serve as an agreement between the SC Bar Law Related Education Division and the individual selected to participate in the Bar’s training session on We the People as indicated above on the selected dates. SC Bar Law Related Education Division Responsibilities: • Provide one classroom set of We the People materials for thirty students. • Provide training and implementation guidelines for the We the People program. • Provide a teacher stipend for participation in the program during the 2018/19 school year • Provide hotel accommodations for teachers more than 30 miles outside of Columbia. • Provide mileage reimbursement for all teachers traveling more than 30 miles each way. Participant Responsibilities: • Attend training session in Columbia, SC. • Teach We the People to at least one class in the 2018-2019 school year. • Answer the Pretest and Posttest for Teachers provided by Georgetown University • Submit the Pretest and Posttest for Students provided by Georgetown University Email or fax the completed form no later than June 15 to: SC Bar: Law Related Education Division Post Office Box 608, Columbia, SC 00000-0000 Phone: (000) 000-0000 Fax: (000) 000-0000 Xxxxxx X. Xxxxxx xxxxxxx@xxxxx.xxx
RESPONSIBILITY AGREEMENT. Waiver Letter Contracting Anthem Blue Cross health care professionals/facilities (“Providers”) are prohibited from charging Anthem Blue Cross Covered Individuals for any service or supply that is determined by Anthem Blue Cross to be not Medically Necessary, unless the Covered Individuals specifically agrees in advance of the provision of the service or supply to be financially responsible for payment with specific knowledge of Anthem Blue Cross’ determination that the service or supply was determined to be not Medically Necessary. This Waiver Letter shall be used by the Provider in such instances and must be separate from any patient payment responsibility information in the hospital admission form. To be effective and valid, this Waiver Letter must be executed prior to the delivery of any service or supply that was determined to be not Medically Necessary. Covered Individual (Patient) Name: ACIS ID: Subscriber ID: Group No.: Provider: Apria Healthcare CPU: COVERED INDIVIDUAL: By signing below, I agree to pay Provider for those services or supplies that Anthem Blue Cross determined were not Medically Necessary. I understand that a Provider may not charge me for a service or supply determined to be not medically necessary unless I have specifically agreed to pay for it in advance and with specific knowledge of Anthem Blue Cross’ determination that the services were determined to be not medically necessary. I also understand that the Provider and/or I may appeal any determination that a service or supply is not Medically Necessary by filing a grievance or appeal with Anthem Blue Cross or the Department of Managed Health Care (“DMHC”) pursuant to the grievance and appeals procedures described in my Benefit Agreement or Evidence of Coverage (“EOC”). I also understand that I may also have the right to Independent Medical Review through the DMHC, as described in my Benefit Agreement or EOC. For the services and/or supplies listed below, I understand that I am financially responsible for payment to the Provider, even though they may not be shown on my Explanation of Benefits (EOB) as my financial responsibility. Date(s) of Service Description of Service and/or Supply Approximate Cost Covered Individual’s (Patient’s) Responsibility See attached Sales Service and Rental Agreement for detailed charges. Signature (Covered Individual/Subscriber Signature): Date:
