Signature of Applicant Date. Acknowledgement I have read and understand Facilities Use Agreement and agree to be bound by the provisions of this permit. Failure to comply with these guidelines may forfeit my rights to usage of facilities. I have provided an application form, the required insurance forms, and a signed letter of indemnification. Signature Date
Signature of Applicant Date. MUNICIPAL CODE SECTION 6-1-59(B) requires payment of all amounts owed to the village before a license can be issued. Every applicant must disclose on his or her application for any license with the Village of Ashwaubenon all amount owed to the Village. Any applicant failing to disclose said debt can be denied. I hereby certify that I do not have any outstanding debts owing the Village of Ashwaubenon.
Signature of Applicant Date. Supervising Medical Staff Attestation I know this applicant and based on my knowledge of this applicant, his/her training, current competence, and health status as it affects performance, I attest that this person is physically and mentally competent to observe in the UW Medicine Clinics or other UW Medicine areas, and is observing for the purpose of medical education, research or training. I attest that the purpose of this is not solely for the benefit of a commercial vendor. I also attest that I will receive the permission of the patient(s) for this person to observe and will introduce the observer to patients. A. The person observing will be in my presence at all times while in the clinical space: Yes No B. If no, the additional Medical Staff Supervisors must sign and date the application and indicate which days they will supervise. See page 4 for the Multiple Accountability Form if applicable. *Please note: Housestaff are not permitted to host observers. Signature: Date: Supervising Physician or Advanced Practice Provider Signature: Date: Department Service Chief (Required if Observation period greater than 30 calendar days or if hosted by an Advanced Practice Provider regardless of length of days) Observation Privileges are Granted only when the HMC Medical Director has signed below: Signature: Date: HMC Medical Director All observers at Harborview Medical Center / UW Medicine must complete the UW Medicine Immunization Health History form on Page 4. Questions about immunization should be directed to Employee Health Services: (000) 000-0000. Return completed Medical Staff Observation Application to: Harborview’s Office of the Medical Director xxxxxxxx@xx.xxx Late or incomplete submissions cannot be accommodated. Multiple Accountability Form *Use this form when multiple physicians or APPs are supervising an observer Please attach any schedules or calendars I certify that will be under my supervision at all times while in the clinical space. Name of Observer (Print) Physician / APP Name (Print/Date) Dates of Supervision Signature Physician /APP Name (Print/Date) Dates of Supervision Signature Physician / APP Name (Print/Date) Dates of Supervision Signature EHS RN and date of review ❑ EHS cleared for service ❑ Additional vaccination or screening TO: Visiting Health Professionals FR: HMC Employee Health Services Manager RE: Communicable Disease Screening Welcome to UW Medicine / Harborview Medical Center. Thank you for your cooperation with our employee he...
Signature of Applicant Date. Signature of PC SCE advisor Date For student: Please submit your signed GATA application to the Providence College School of Continuing Education: 000 Xxxxx Xxxxxx, Xxxxxxxxxx, XX 00000, Attention: SCE; fax to 000-000-0000; scan and email to xxx@xxxxxxxxxx.xxx You may request a copy for your records.
Signature of Applicant Date. Rental Fees A $50 deposit fee is required (by check). Please send separate checks, one for the deposit and one for the rental fee as calculated above. This deposit will be returned following an inspection by the maintenance overseer and a determination that the premises were not damaged. Rental of Rec Building including Kitchen $50 Rental of Pavilion $50 Rules and Responsibilities Users must sweep, remove trash, and generally clean the building after use. Tables and chairs must be arranged as found, and no furniture is to be removed from the building. All dishes must be washed, dried, and put back into the cupboards. Tables, chairs, or other furniture brought in to the building must have protective footings. Remember to lift the furniture - do not slide it across the floor. Pets are not allowed in the building. No smoking in the building. Alcoholic beverages are not allowed on the Township property unless prior approval is obtained from the Township Board, including a Certificate of Liquor Liability. It is recommended that you obtain liability insurance for your event. You may have this type of insurance added to your homeowner’s policy for a minimal fee. Please return this form along with your deposit and rental fee to: XX Xxxx, Town of French, PO Box 28, Side Lake, MN 55781.
Signature of Applicant Date. Please keep the attached Conditions and Regulations page and Concussion and Sudden Cardiac Arrest information for your reference. Date(s) Requested: Start Date: End Date (if event is re-occurring, see procedure below): Time Start: Time End: Set-up Time (If Needed): Break down Time (If Needed):
Signature of Applicant Date. FOIP Notification: The personal information you provide on this form is being collected under the authority of the Freedom of Information and Protection of Privacy Act and is used solely for purposes relating to the administration of Assessment/Taxation services. Questions about the collection or use of this information can be directed to the City of Xxxxxxx Taxation Clerk at (000)000-0000.
Signature of Applicant Date. Please keep the attached Conditions and Regulations page and Concussion and Sudden Cardiac Arrest information for reference. Date(s) Requested: Start Date: End Date (if event is re-occurring): * For re-occurring requests, see procedure below. Time Start: Time End: Set-up Time (If Needed): Break down Time (If Needed): Area or Space Requested: 1st and 2nd Choice: Day(s) of the Week: Sun Mon Tues Wed Thurs Fri Sat ES ASK Room ES Play Ground ES Classroom- Rm # ES Gym HS Practice Field HS Gym HS Concession Kitchen HS Library K-8 Cafeteria K-8 Community Kitchen K-8 Play Shed (no restrooms) K-8 Entry Way HS Band Room HS Baseball Field HS Challenge Course HS Classroom-Rm # HS Parking Lot HS Track HS Softball Field HS Stage K-8 Main Athletic Field K-8 Library K-8 Softball Field MS Gym HS Commons HS Weight Room MS Classroom-Rm # HS Conference Room Other: Specify: MS Conference Room ***TO PROVIDE LA CENTER SCHOOL DISTRICT STUDENTS PRIORITY ACCESS TO GYM AND FIELD SPACE *** * For youth sports teams or groups that request space on an ongoing basis, the team or group must be made up of not less than 70% La Center School District students. A team roster must be attached to the facility request form. To ensure equity in the use of space, teams may not request more than 3 months (a quarter) of space at a time. Please limit requests to 2 days per week. **To request a specific quarter, requests need to be submitted for processing by the 20th of the month prior to the beginning of the quarter. **Quarters will be divided as follows: Quarter 1 - September, October, November (request space by Aug. 20) Quarter 2 - December, January, February (request space by Nov. 20) Quarter 3 - March, April, May (request space by Feb. 20) Quarter 4 - June, July, August (Limited use during summer months, request space by May 20) Once the quarter has begun, if space is still available, then requests will be processed on a first come first serve basis. Description of event to take place: (continued on reverse) Phone: 000-000-0000 / Fax: 000-000-0000 Approximate number of people attending: Is the event open to the public? Will food and beverages be available for consumption during this event? Yes Yes No No Does your organization hold non-profit status? Yes No If yes, proof is required. Is this a revenue generating event? Yes No If you are requesting use of a field, would you like to be notified of any chemical spraying that is scheduled for that field during your requested time? Yes No Proof of ins...
Signature of Applicant Date. I further agree to authorize the Crow Adult Vocational Training Program personnel to request and receive personal income information from the following sources: Sign each line that applies to you
Signature of Applicant Date. Please keep the attached HEAD INJURY PROCEDURE for reference.
