COVID-19 INFORMED CONSENT AGREEMENTInformed Consent Agreement • December 16th, 2020
I, the undersigned patient, consent to an in-person consultation and/or to have my Doctor and/or his/her staff (hereinafter collectively “my Doctor”) perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand in-person consultations and/or having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death. I am also aware of the possibility that the procedure itself, whether performed in my Doctor’s office or in a hospital, may result in a more severe case of COVID-19 than I might have had without the procedure.
INFORMED CONSENT AGREEMENT FIELD TRIP - MULTI-DAYInformed Consent Agreement • November 16th, 2022
As a condition of participation in field trips lasting overnight or longer, this form must be completed by the parent/ guardian of each student participant.
INFORMED CONSENT AGREEMENT COUNSELING SERVICESInformed Consent Agreement • April 4th, 2022
This document contains important information about our professional counseling services and business policies. It also contains a summary of information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. We can discuss any questions you have prior to any therapeutic services being rendered or at any time in the future.
Informed Consent Agreement forInformed Consent Agreement • July 17th, 2020
Plymouth State University is looking forward to welcoming students, faculty, and staff back to our campus for in-person instruction. We will need the help, cooperation, and participation of you and every other member of our on-campus community to maintain a reasonably healthy and safe campus environment. While none of us can ensure that the campus will be free from the risk of contracting the novel coronavirus, COVID-19, by working together we can manage and mitigate the risk. We ask you to help reduce the risk of transmission by staying current on information about the virus provided by public health officials and experts. The University has established and implemented public campus-wide protocols designed to limit the spread of COVID-19 on the campus and to help safeguard vulnerable persons on campus, in Plymouth, and in the wider community for the 2020–21 academic year. The protocols are available on the University’s Fall 2020 Opening website and the Dean of Students website. Failur
INFORMED CONSENT AGREEMENTInformed Consent Agreement • August 6th, 2020
We, the UNDERSIGNED hereby acknowledge that certain RISKS OF INJURY are inherent to participation in sports and recreational activities. Including but not limited to: SKATEBOARDING/ IN-LINE SKATING/ SCOOTERING/ ROLLER SKATING/DROP-IN RECREATIONAL ACTIVITIES/ROCKCLIMBING. We consent to
Informed Consent Agreement Supporting InformationInformed Consent Agreement • September 15th, 2020
Yuan Qiong and REN XUE seek to recognize the root causes of symptoms or disease. Yuan Qiong is a comprehensive system that cultivates life as a whole, addressing the imbalances or blockages of Qi (energy) that contribute to illness and problems in life.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • June 7th, 2021
We hereby consent to allow the student named on the reverse side to undergo urinalysis and/or hair follicle testing for the presence of illicit drugs, alcohol, or banned substances in accordance with Policy and Procedures for Drug Testing of the Clermont Northeastern Schools District.
Vermilion Local School District INFORMED CONSENT AGREEMENTInformed Consent Agreement • April 29th, 2015
• I understand and agree that participation in extracurricular activities, special privileges and/or parking on school grounds is a privilege that may be withdrawn for violations of Board Policy 5530.01 - Drug Testing Policy, hereinafter Policy.
Informed Consent AgreementInformed Consent Agreement • October 4th, 2021
The best relationships are those that are built on respect and understanding. My informed consent agreement gives you understanding as to my responsibilities as a therapist/healthcare practitioner and your responsibilities as a client.
Informed Consent AgreementInformed Consent Agreement • March 2nd, 2021
INFORMED CONSENT AGREEMENT – SPORTInformed Consent Agreement • January 16th, 2022
In order for any student to participate in school sports it is a requirement for both the student and a parent/ guardian to complete the following:
Informed Consent AgreementInformed Consent Agreement • October 7th, 2009
This is an Informed Consent Agreement, which identifies risks of participating in a Weber State University event, course or program, and a Waiver and Release for participants.
Informed Consent AgreementInformed Consent Agreement • October 28th, 2020
I, the undersigned, hereby acknowledge that certain RISKS OF INJURY are inherent to participation in sports, exercise, and recreational activities. These types of injuries may be minor or serious and may result from one’s own actions, or the actions or inactions of others, or a combination of both. I also understand that it is my responsibility to become knowledgeable about and how to minimize or prevent the risks associated with the activities I choose to participate in. I understand that there is a very remote possibility (e.g., accident) that I might be exposed to bodily fluids (i.e., blood), which may contain the Hepatitis B agent or HIV virus. Please notify the instructor immediately for instructions in dealing with this situation.
INFORMED CONSENT AGREEMENT (PARENT/CHILD)Informed Consent Agreement • August 30th, 2018
[Brief description of key information to assist in understanding the reasons why one might or might not choose to participate in the research, organized and presented in a way that facilitates comprehension]
INFORMED CONSENT AGREEMENT – SPORTInformed Consent Agreement • October 3rd, 2013
As a condition of participating in school sports, this form must be completed by the parent/guardian of each student participant or by the student if over the age of majority (18). This includes all sports sanctioned by the York Region Elementary School Athletics Association (YRESAA) and York Region Athletic Association (YRAA). This does not include activities that are part of regular physical education program.
Informed Consent Agreement for Students Participating in On-campus Programming for the Fall SemesterInformed Consent Agreement • July 17th, 2020
The University of New Hampshire (UNH) is looking forward to welcoming students, faculty and staff back to our campuses for in-person instruction. We will need the help, cooperation and participation of you and every other member of our university community to maintain a reasonably healthy and safe environment. While none of us can ensure each campus will be free from the risk of contracting COVID-19, by working together we can manage and mitigate the risk. We ask you to help reduce the risk of transmission by staying current on information about the virus provided by public health officials and experts. UNH has established and implemented public university- wide protocols COVID-19 website page designed to limit the spread of COVID-19 on its campuses and to help safeguard vulnerable persons on its campuses, in the Town of Durham, in the cities of Manchester and Concord, and in the wider community for the 2020-21 academic year.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • December 21st, 2006
The purpose of this Informed Consent Agreement is to inform you that your son/daughter is eligible to receive services at Weber State University, hereinafter WSU. Your signature will authorize and allow your son/daughter to receive these services. You may choose to sign any of the following parts, all of them, or none of them.
Informed Consent AgreementInformed Consent Agreement • July 14th, 2015
INFORMED CONSENT AGREEMENTInformed Consent Agreement • September 26th, 2022
Thank you for choosing to use the services, or programs of Redwood Therapy. We request your understanding and cooperation in maintaining both your and our safety and health by reading and signing the following informed consent agreement.
Informed Consent Agreement Information about Being in a Research Study Texas A&M University-CommerceInformed Consent Agreement • April 9th, 2018
Dr. Jangsup Choi, Dr. Salvatore Attardo, Dr. Ricky Dobbs, and Jason McCain (Texas A&M University-Commerce) are inviting you to participate in a web-based online survey on an open textbook use study.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • April 16th, 2019
During your first session, your therapist will discuss several important issues with you. This form will help acquaint you with the nature of our services. Please ask for clarification of any issue that may concern you. Please initial each blank space if you understand and agree with what is stated.
Informed Consent AgreementInformed Consent Agreement • June 7th, 2022
Welcome to Counseling. It is my intention to provide you with confidential counseling designed to help each individual achieve their personal goals. My services and programs aim to cultivate self-awareness, interpersonal skills and well-being. All services are conducted in a manner that is positive, collaborative, empowering and respectful of the diversity of my clients. This document will provide you with important information about my services and your rights as a person receiving counseling. Please read all of the information carefully, ask any questions so that I may address your concerns and sign the final page.
INFORMED CONSENT AGREEMENT FORMInformed Consent Agreement • October 13th, 2015
Patient access to the Appletree Patient Portal is granted by signing the following consent agreement and acknowledging the Terms of Use prior to accessing the service online.
Informed Consent AgreementInformed Consent Agreement • September 8th, 2021
We offer services to our part-time and full-time students, faculty, staff, as well as family members of those previously listed for a variety of personal, academic, and career concerns at no charge. Students are eligible for services during the summer if they are enrolled for summer courses or pre-registered for courses in the following fall semester. All who fall outside our scope of services will be referred to professionals in the community.
Informed Consent AgreementInformed Consent Agreement • November 3rd, 2011
I, _________________________ , hereby agree to serve as a subject in the research project titled “Regional Attitudes towards Climate Change” It has been explained to me that its purpose is to gather information about local attitudes and activities about climate change. The research activity I will participate in is a 60-120 minute audio-recorded interview.
Informed Consent Agreement, Assumption of Risk, Release of LiabilityInformed Consent Agreement • March 10th, 2020
Ignite Circus* is committed to creating an environment of safe, non-competitive learning and activity for the physical and overall well-being of its participants and staff. The following behaviour by participants, their parents, friends, observers or any others will not be tolerated and will lead to dismissal of the participants from the program offered by Ignite Circus, including but not limited to:
INFORMED CONSENT AGREEMENT – SPORTSInformed Consent Agreement • October 3rd, 2013
As a condition of participating in school sports, this form must be completed by the parent/guardian of each student participant or by the student if over the age of majority (18). This may include sports sanctioned by the York Region Elementary School Athletics Association (YRESAA) and York Region Athletic Association (YRAA). This does not include activities that are part of regular physical education program.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • October 8th, 2021
INFORMED CONSENT AGREEMENTInformed Consent Agreement • February 1st, 2005
INFORMED CONSENT AGREEMENTInformed Consent Agreement • October 7th, 2020
INFORMED CONSENT AGREEMENTInformed Consent Agreement • October 16th, 2021
Welcome to Awakenings Counseling Center (ACC). We appreciate you giving us the opportunity to be of help to you. It is our hope that this brochure will answer some questions that most clients often ask about any therapy practice. We believe our work together will be most helpful to you when you have a clear idea of what we are trying to do. After you read this brochure we can discuss in person how these issues apply to your own situation. This brochure is yours to keep and refer to later. Please read all of it and write down any questions you may have. When you have read it and fully understand it, please sign it. We will make you a copy of the signed page.
Informed Consent AgreementInformed Consent Agreement • August 14th, 2014
University of Central Arkansas Informed Consent AgreementInformed Consent Agreement • August 5th, 2020
This virtual focus group session is sponsored by the Office of Institutional Diversity and Inclusion Minority Vendor Partnership Initiative at the University of Central Arkansas and the Women’s Foundation of Arkansas. The session will be monitored by Kristy Carter, director of marketing for the Division of Outreach and Community Engagement and member of the Minority Vendor Partnership Initiative committee at UCA and Principal Investigator of the study, who can be reached by email at kcarter@uca.edu or by phone at (501) 450-3139.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • February 27th, 2012
Informed Consent AgreementInformed Consent Agreement • June 5th, 2016
