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.
Parental approval to participate in hypnotism show(please circle answer): YES NO Parent/Guardian Name (Please Print) Home Phone Home Address Cell/Alternate Phone Number Parent/Guardian E-mail Address - please print clearly Student E-mail Address Emergency Contact Name - Available Night of Event Emergency Phone Number - Available Night of Event Parent/Guardian Signature Date PLEASE CHECK THE APPROPRIATE STATEMENT REGARDING STUDENT’S HEALTH: My child has no known health problems.
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: Physician: Phone: Potential life threatening medical condition diagnosed as:
Emergency Contact Name. Address: Phone: (_ )_ Vehicle information (make, model, color, plate) Make Model Color Plate# * * * *Any additional vehicles that may use seasonal permit Max of 2 vehicles on site at one time. 3rd vehicle MUST obtain ‘3rd vehicle permit’ and park in Xxxxxx or beach parking lot.
Emergency Contact Name. Address: Relationship to You: Phone#: University shall maintain all health records and information about participants in compliance with all applicable HIPAA and FERPA laws and regulations. _ I hereby acknowledge that I have read and understand the information presented to me in the (initial) Participation Agreement. Signature of Participant Date Printed Name of Participant NCSU ID#