Application Form 2017
|
|
|
- Stewart Hart
- 5 years ago
- Views:
Transcription
1 Application Form 2017 Check the box for the project in which you wish to participate: Ghana (August 13-20, 2017) Malawi (August 13-20, 2017) Caribbean (July 30 August 3, 2017) Chile (July 30 August 3, 2017) GENERAL INSTRUCTIONS: Be sure to review the Project Fact Sheet, including dates, exact locations, fees, and where to send applications. PERSONAL INFORMATION Applicant's name (print): Last First Middle Date of Birth (mm/dd/yyyy): Sex: Male Female Hold valid passport? Telephone number: ( ) (print clearly): 2 x 2 Photo (For electronic version, click this box to attach applicant s photo.) Do you attend church regularly? Are you baptized? UCG Congregation: Pastor's name: Pastor's phone: ( ) Note: Application cannot be processed without a recent photo Shirt Size: Small Medium Large X-Large Date of Photo: Have you served as a staff member at one or more United Youth Camps or Youth Corps? If yes, when, where & in what capacity? EDUCATION Highest degree attained (High School Diploma, Associate s, Bachelor s, Master s, etc.): Currently enrolled in a formal degree plan? If so, what & where: Have you studied any foreign languages? If so, which one(s) & describe experience/proficiency to read, write, and speak: SKILLS / EXPERIENCE Please indicate any particular athletic or other skills please comment on level of proficiency as well: SKILL Proficiency SKILL Proficiency SKILL Proficiency Swimming Computer Skills Other: Volleyball Teaching English Other: Basketball Rock Climbing Other: First Aid/CPR Soccer Other:
2 REFERENCES Please provide four references (including your pastor) who know you well: Pastor: #2: #3: #4: TRAVEL EXPERIENCE Name Phone Previous international travel is not a prerequisite for acceptance, but it helps us plan if we know your level of international travel experience. Please list any international travel you have done and describe when, where and how long you stayed: HEALTH HISTORY Check if you have had any of the following: Eyesight Impairment Mental or Emotional Disorders Intestinal Disorders Heart Disease Ear or Hearing Problem Chicken Pox Rheumatic Fever Speech Impairment Severe Menstrual Pain Measles Hernia Disorders of Nervous System Arthritis Mumps Hayfever or Asthma Sinusitis Diabetes German Measles Other Serious Allergies Disease of Kidneys Tuberculosis Abnormal Blood Pressure Other Serious Illness or Disability: Immunizations Fill in the dates for any of the following immunizations applicant has had: Immunization Date Last Received Date Last Received Hepatitis A or immune globulin (IG) Typhoid TD (tetanus-diphtheria) DPT Tetanus Chicken Pox Hepatitis Rabies Polio Yellow Measles Smallpo Rubella NOTE: Certain immunizations are required by various countries for entry. You will be given more details on which ones are required for travel to the project you selected. Also, other medications (for malaria, for example) will be highly recommended as well depending on the country in which the project is based. Are you taking any medication or receiving medical care for a particular condition on an ongoing basis? If yes, please explain (attach note if necessary): Please set forth (or elaborate on) any illness, disability or any other condition or limitation that could affect your participation in the corps (if none, so state): In order to participate would you need special accommodation(s) or equipment? If yes, please describe those special needs:
3 CRIMINAL RECORD Have you ever been indicted, charged with or convicted of child abuse, child molestation, child neglect, sexual assault, rape or any other sex crimes, drug crimes, violent crimes or any felonies? Is any such criminal case currently pending against you or on appeal? If convicted, penalties imposed: If yes, what were you convicted of? Date(s) of indictment(s), charge(s) or conviction(s): CIVIL RECORD (Lawsuits) Have you ever had a lawsuit filed or civil judgment entered against you, or is there a pending complaint against you concerning intentional injury against others, your treatment of minors or any other unchristian behavior? Location(s) of case(s): Case number(s): Date(s) of suit(s): Is any such civil case currently pending against you or on appeal? INSURANCE If a judgment was entered against you, state its requirements: The Church s no-fault accident insurance is limited ($10,000 per person) and secondary to any other collectible insurance. Please furnish the following medical and insurance coverage information: Insurance Company: Policy or Group # Type of coverage(s): Is overseas travel covered? Social Security Number of policy holder or insurance ID number: Insurance Phone # ( ) Family Physician: Physician s Phone # ( ) SPECIAL EXPERIENCE or ABILITIES In your own words, explain any special skills or abilities you can bring to the project: REASON FOR APPLYING In your own words, explain why you want to participate in this project:
4 REASON FOR APPLYING (cont d) AGREEMENT AND RELEASE Applicant s signature: All United Youth Corps Projects will maintain a high standard of conduct and dress, based on God's laws. These standards and rules include, but are not limited to: No possession or use of tobacco, or illegal drugs, no sexual misconduct, theft, disorderly conduct, profanity, no destruction of property, or refusal to cooperate fully with the project staff. Short shorts, midriffs, halter-tops, or wearing revealing or other inappropriate apparel (or the lack of appropriate clothing) will not be allowed. Firearms or other weapons (except pocketknives) may not be brought without the written permission of the project director. Participants who do not comply with the project's rules and standards, or whose conduct or attitude undermines the positive environment and objectives of the project, or who have made any false, misleading or incomplete statement in this application are subject to being dismissed. If the participant is dismissed, he or she will be sent home at his or her own expense. By my signature(s) below, I also hereby give consent and permission to the non-exclusive, non-commercial reproduction, publication, or use by United Church of God, an International Association ( Church ) or anyone authorized by them, of any pictures or photographs (still, video or motion, individual or group), taken of the applicant at any United Youth Corps project or its related activities (including travel), or if taken during any other Churchrelated activities, together with any caption or descriptive material, including the individual s name, without compensation to the undersigned. Said picture(s) may be used, without limitation, on Church Web site(s), in Church publications, in Festival or other videos or promotions created by the Church, in Church sponsored advertising, or in any television program or broadcast approved by the Church. Applicant: I have read, fully understand, and agree to comply with all the rules and standards of the project and its staff. I understand and agree with its implications and the stated consequences. I also affirm that the information given in this application is true and complete and that I am in good health and able to participate (or will be able to participate with the accommodation(s) described above) in the expected activities and routine for the project(s) marked on the front. In consideration being allowed to participate, I hereby release, indemnify, save and hold harmless and covenant not to sue the United Church of God, an International Association, their officers, Council of Elders, agents, employees, volunteers and helpers and any other related entity (hereinafter collectively called the Church ) from all actions, claims, demands or suits which are based upon, or result from injuries sustained arising out of, or in the course of, participation or attendance at the project, even if caused by the Church s negligence. This release, however, shall not apply to claims covered by the Church s liability and no fault accident insurance, but is applicable to claims not covered by that insurance. It is recommended that you have your own insurance protection since participants are involved in activities at their own risk, and the Church's no-fault accident coverage is secondary and quite limited ($10,000 per person). I understand (unless otherwise specifically stated in the project description) that I will be a volunteer without any expectation of compensation and that I will be responsible for all the expenses related to the project for which I am accepted including, without limitation, travel expenses, clothing, meals and lodging. I will be responsible for complying with any passport and visa requirement of the country where I am to serve. X Applicant Who should be contacted in case of emergency? Date
5 TRAVEL WAIVER I have logged onto the U.S. Department of State s Web site at and read the Travel Warning for (country in which I am applying for UYC service):, and understand the risks that travel in this country might entail. I realize that the United Church of God / United Youth Corps has taken precautions to address reasonable security or health concerns through the training and advice given prior to the trip. I hereby release, indemnify, save and hold harmless and covenant not to sue the United Church of God, an International Association, their officers, Council of Elders, agents, employees, volunteers and helpers and any other related entity (hereinafter collectively called the Church ) from all actions, claims, demands or suits which are based upon, or result from injuries sustained arising out of, or in the course of, participation or attendance at the project, even if caused by the Church s negligence. This release, however, shall not apply to claims covered by the Church s liability and no-fault accident insurance, but is applicable to claims not covered by that insurance. It is recommended that you have your own insurance protection since participants are involved in activities at their own risk, and the Church's no-fault accident coverage is secondary and quite limited ($10,000 per person). I understand (unless otherwise specifically stated in the project description) that I will be a volunteer without any expectation of compensation and that I will be responsible for all the expenses related to the project for which I am accepted including, without limitation, travel expenses, clothing, meals and lodging. I will be responsible for complying with any passport and visa requirement of the country where I am to serve. X Applicant Date Send the completed application before the deadline date to: Lena_VanAusdle@ucg.org Deadline: April 21, /16/2017
Application Form
Application Form -- 2018 Check the box for the project in which you wish to participate: Mexico (Youth Camp) July 22-July 29, 2018 (and travel time) GENERAL INSTRUCTIONS: Be sure to review the project
Town of Dover Recreation Department Day Camp Registration Form
Town of Dover Recreation Department Day Camp Registration Form Name of Camper: Address Age Grade Entering in fall Male/Female Phone # Cell # Date of Birth (Please circle all that apply) Full Day 1. Session
WRAP/YMCA Expanded Learning Program
2018-2019 School Year School: Child s Last Name: First Name: Sex: M F Birth date: / / Age: Home Phone: ( ) Home Address: Cell Phone: ( ) City: State: Zip: Child lives with: Mom Dad Both Parents Other Begin
2017 Parkway Fellowship Student Ministries
2017 Parkway Fellowship Student Ministries Medical Release Form I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by Parkway Fellowship and Student Ministries.
2018 Registration Form
2018 Registration Form Camper s Name: Birth Date: Grade (completed in 2017) School: T-shirt Size: YS YM YL AS AM AL AXL Billing Name: Address: STREET CITY STATE ZIP Email Address: Note: Camp statements
Elite Athlete Strength and Conditioning Camp
Elite Athlete Strength and Conditioning Camp For your child s safety, and in order to be permitted to participate in all activities, please fill out this form and return it to St. Michael s Summer Camps
Vapor Ministries Trip Application Form
Vapor Ministries Trip Application Form Name/date of Vapor trip you are applying for Applicant Information Legal Name (as it appears on passport) Name you prefer to be called Date of birth Gender (please
2015 YOUTH SUMMIT: TOGETHER WE CAN
2015 YOUTH SUMMIT: TOGETHER WE CAN What is Project UNIFY? Project UNIFY is a sports and education program that partners students with and without intellectual disabilities to create a more inclusive school
WWBA Basketball Camp
WWBA Basketball Camp 2018 Personal Health and Medical Record Camper Name Date of Birth Address Age Sex City / State Zip Code Emergency Contacts (Parents/Guardians should be the emergency contact, however,
Child s Name. Home Address CO. Home/Cell Phone Sex M F Age Date of Birth. Mother or Guardian s Name Job s Address
CAMPER APPLICATION CAMP DATES: June 26 th July 1 st 2016 Volunteers of America Programs are available to any eligible person regardless of race, color, national origin, religion, sex, age, sexual orientation,
For office use only: Agency Participant. T-shirt received Shirt size: Adult- M L XL
SUMME ER DAY CAMP WEINGART-LAKEWOOD FAMILY YMCA REG GISTRA ATION PACKE ET For office use only: Agency Participant Year Round Participant T-shirt received Shirt size: Youth- XS S M L Adult- S M L XL SUMMER
Summer Day Camp 2012-Registration Form (Each child requires a separate registration form)
GARDENA-CARSON FAMILY YMCA 1000 W. Artesia Blvd., Gardena, CA 90248 P 310 523-3470 F 310 539 6049 www.ymcala.org/gc Office Use Only Membership I.D. # Receipt # Date Packet Waiver Staff Initial Shirt Rec
Guatemala Trip Travel Forms
Guatemala Trip Travel Forms To Grow in Faith and Carry On the Works of Jesus Christ Multi-generational trip to Guatemala An opportunity for men, women, and families to travel, learn, and serve together.
TEAM TRAVEL MANUAL. Table of Contents. I. General Info About Belize Project Important Dates & Deadlines
TEAM TRAVEL MANUAL Table of Contents I. General Info About Belize Project Important Dates & Deadlines II. Forms Interest Form Important Details and Paperwork Travel Agreement Form Emergency Data Form Passport
MAILING ADDRESS AREA CODE + PHONE NUMBER ZIP
Kentucky District Pathfinder s Mission Trip Application Packet Life Bridge Inner City Missions Savannah, Georgia June 1 June 7, 2009 Mission Trip Fee $400.00 per person LAST NAME FIRST NAME DATE OF BIRTH
Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
Knox Presbyterian Church Volunteer Staff Medical Authorization, Health History, and Youth Ministry Release for 2018/19
Knox Presbyterian Church Volunteer Staff Medical Authorization, Health History, and Youth Ministry Release for 2018/19 Name of Participant (Please print your first and last name.) Age: Birth date Gender:
PATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
Colorado Trek Paper Work Check List
Colorado Trek Paper Work Check List Please make sure you have all your paperwork before sending it in Due June 2 - Paperwork Due June 2 - Full payment of $2400 NAME HATS Release Form Adventure Experience
Fellowship Baptist Church Youth Ministry Permission Forms
Fellowship Baptist Church Youth Ministry Permission Forms Fellowship Baptist Church, Youth Ministry, and Volunteers Are Designated By The Abbreviation FBC Throughout This Entire Form GENERAL PERMISSION
2018 Jr. Celtics School Vacation Week Two Day Clinic Registration Packet
2018 Jr. Celtics School Vacation Week Two Day Clinic Registration Packet For more information call 617-399-8432 or email Sam at: jrceltics@celtics.com When: Monday, February 19, 2018 & Tuesday, February
Florida Hospital Global Mission Initiatives Registration Form
Florida Hospital Global Mission Initiatives Registration Form Name (Last, First Middle - as shown on passport) Go-by Name Today's Date E-mail Phone No. Date of Birth Address City, State, Zip Gender T-Shirt
2018 EMPLOYMENT APPLICATION
Date Name 2018 EMPLOYMENT APPLICATION 718 Professional Drive ~ Shreveport, LA 71105 318-779-1451 ~ rocksolidathletic@gmail.com Gender Social Security # Date of birth Current Address Street City State Zip
VOLUNTARY SHORT TERM MISSION SERVICE Participant Application. Name: Last First Middle Address: City: State: Zip:
VOLUNTARY SHORT TERM MISSION SERVICE Participant Application Name: Last First Middle Address: City: State: Zip: Home Phone: Cell: DOB: Work: Email: Age: Citizenship: T-Shirt Size: Social Security #: D.L.
girls empowerment camp registration form 2015
Pasadena-Foothill Valley YWCA PASADENA-FOOTHILL VALLEY girls empowerment camp registration form 2015 Note: A $20.00 non-refundable registration fee applies to all applicants and is due upon registration.
HAPCO Music Foundation PO Box Winter Garden, FL hapcopromo.org
Student Forms complete and return to HAPCO Release and Indemnification Agreement Contact/Medical Information Form Insurance Consent & Medical Authorization Physician Authorization Form Permission to Drive
Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM
Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM Section 1 Basic Contact Information Campers Name: _ Nickname:_ Birth date / / Gender: Male Female T-shirt size: Adult / Youth
OHIO CAMPus REC Summer Camp
OHIO CAMPus REC Summer Camp AGREEMENT AND RELEASE OF LIABILITY FORM This release executed by the Undersigned on behalf of [Name of Participant] with an address at ( Participant ) to Ohio University, Athens,
CSUF/NSM. Application Environmental Science Research in Thailand
CSUF/NSM Application Environmental Science Research in Thailand Application Checklist ESRT Application (sign the application) Permission for Emergency Treatment Release of Liability Personal Conduct Form
ATHENS YMCA CAMP KELLEY SUMMER CAMP 2018
ATHENS YMCA CAMP KELLEY SUMMER CAMP 2018 POLICIES Cost: Full Week (5 Days) $115, Half Week (3 Days) $70; Additional Children: Any additional children will receive a $10 discount on full weeks ONLY. Registration
2017 ACES Family Academies Requirements for Registration
2017 ACES Family Academies Requirements for Registration The attached forms must be sumbitted by the deadlines noted below for on-line registration for the 2017 College of ACES Family Academies to be valid.
CSUF/NSM. Application Environmental Science Research in Thailand
CSUF/NSM Application Environmental Science Research in Thailand Application Checklist ESRT Application (sign the application) Permission for Emergency Treatment Release of Liability Personal Conduct Form
Child Health/Dental History Form
Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M
Application to Serve as a Diakonos at the Iowa United Methodist Annual Conference Hy-Vee Hall in Des Moines, Iowa - June 7-11, 2019
Application to Serve as a Diakonos at the Iowa United Methodist Annual Conference Hy-Vee Hall in Des Moines, Iowa - June 7-11, 2019 Name: Grade Completed this year: Home Church: District: SE EC NE SC C
Faculty Program Study Abroad Application & Information Packet
2017 2018 Faculty Program Study Abroad Application & Information Form Applicant Name: Page 1 of 8 Faculty Program Study Abroad Application & Information Packet Participant Information This form will help
Please print and submit your study abroad application and deposit to the FVCC Business Office in Blake Hall.
2018 Conservation Ecology in Ecuador/ Galapagos Islands Deposit Form Please print and submit your study abroad application and deposit to the FVCC Business Office in Blake Hall. Upon receipt of your deposit
Summer Camp Application INTERNATIONAL DEVELOPMENT 101
INTERNATIONAL DEVELOPMENT 101 Student Information Student Name: Sex : Male / Female Student Preferred/Nickname: Mailing Address: Home Phone Number: Cell Phone Number: School: Grade (Entering): Date of
CAMP/CLINIC DATES: July 21 22, 2018 and/or August 11 12, 2018 MEDICAL HISTORY. Street City State Zip
Please fill out this form completely. It is important for the provision of proper medical care. The section marked Physician s Comments need only be completed if the participant has a major health problem.
Summer Camp 2015 Registration Form
Summer Camp 2015 Registration Form Complete all 5 pages and return to MJCC, 6560 Poplar Avenue, Memphis TN, 38138. One form per camper. Additional forms are available at the MJCC Member Services Desk or
Middle School Mathematics Camp Monday through Thursday 9:00am 1:00pm
Monday through Thursday 9:00am 1:00pm Registration Form Name last first middle Mailing Address street city state zip School Gender School District Grade in September 2018 (6, 7, 8, or 9) Phone # Age Tee-shirt
ANTEATER RECREATION SUMMER CAMP
ANTEATER RECREATION SUMMER CAMP COMPLETING YOUR WAIVER FORMS All forms have the ability to be completed through Adobe Acrobat. At this time, the University still requires inked (not electronic) signatures.
There are a few things we need from you to make sure we are able to create the best camping environment possible:
Dear Counselor Applicant: The WAPAC Kid s Camp Team would like to thank you for offering your time to make a difference in the lives of children during the week of camp. Being a counselor is an awesome
University of Illinois Extension, Kane County 535 S. Randall Rd. St. Charles, IL 60174
Serving DuPage, Kane & Kendall Counties 535 S. Randall Rd., St. Charles, IL 60174 Phone 630/584-6166 FAX 630/584-4610 http://web.extension.illinois.edu/dkk/ October 2017 For those interested in continuing
We are excited to offer Camp Good Grief for free. This day camp is filled with fun and adventurous camp activities combined with grief support.
Dear Parent/Guardian, Thank you for interest in Hospice of Michigan's Camp Good Grief hosted at Camp Newaygo 5333 S. Centerline Rd, Newaygo, MI 49337 on Friday June 16, 2017 from 8am-4pm. We are excited
FAIRVIEW SCHOOLS BERHAD (43809-K) STUDENT APPLICATION FORM AND CONTRACT
FAIRVIEW SCHOOLS BERHAD (43809-K) STUDENT APPLICATION FORM AND CONTRACT KINDLY SUBMIT THE FOLLOWING WITH THE APPLICATION FORM: 1. Two passport-sized photographs of the student 2. Student s Birth Certificate
University of Rochester Elite Girl s Lacrosse Camp
University of Rochester Elite Girl s Lacrosse Camp University of ROCHESTER welcomes you Date: Saturday August 8, 2015 thru Sunday August 9, 2015 Time: Check-in: Saturday August 8 Resident Campers: 1:00-3:00
Registration Form Trek Jordan 2019
Please return your completed, signed form to JCH along with your deposit in order to confirm your place on the trek. Trip: TREKS- Jordan Trip Date: 5 th -12 th October 2019 All information must be as per
Patient Information Patient Info. Update
Medical History Brian R. Carr, D.D.S., M.D Patient Information Gagandeep Pandher,D.D.S. Patient Info. Update Date Date Initials Date Initials Name Address Cell Phone # City State Zip Work # Date of Birth
D.M.G. Athletics. The Official Indoor/Outdoor Summer Basketball League. Team Registration Packet
D.M.G. Athletics Presents The Official Indoor/Outdoor Summer Basketball League Team Registration Packet Questions: Contact Coach Dawne Gittens at 860-929-7692 or via email at dgittens@bgchartford.org Team
Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland
Germantown Smiles,PC 19735 Germantown Road Suite 225 Germantown, Maryland 20874 240-654-3302 Patient Information Patient Name: Last First MI Gender: Male Female Family Status: Married Single Child Other
The Salvation Army Ray & Joan Kroc Corps Community Center. Summer with RJ Day Camp Camper Enrollment Form- 2015
1 The Salvation Army Ray & Joan Kroc Corps Community Center Summer with RJ Day Camp Camper Enrollment Form- 2015 Basic Camp information: Camp dates are from 7/6/15-9/4/15; Camp hours are from 9am- 5pm;
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
Asheville-Buncombe Technical Community College Study Abroad Program Application
Asheville-Buncombe Technical Community College Study Abroad Program Application Application instructions Please read these instructions completely. ELIGIBILITY A-B Tech Study Abroad programs are for current
Welcome to Pediatric Dentistry of Greenville!
Welcome to Pediatric Dentistry of Greenville! Child's Information Child's Name(Last, First, Middle Initial) Child's DOB: / / Child's Age Nickname: ( ) Male ( ) Female School : Grade: Child's Home Phone
CAMPER INFORMATION SHEET RIVERS EDGE. Camper Name: Camper Birth Date: Group Attending With: Parent Name(s): Contact Address: Contact Phone:
CAMPER INFORMATION SHEET RIVERS EDGE Camper Name: Camper Birth Date: Camper Gender: M or F Group Attending With: Parent Name(s): Contact Address: Contact Phone: Contact Email: Camp Eagle 6424 Hackberry
CAMP ENROLLMENT FORM
CAMP ENROLLMENT FORM *This camp program is a tuition for service program, based on confirmed enrollments and secured deposits. A $35 per camper, per session non-refundable and non-transferable deposit
DUKE SUMMER CAMP HEALTH FORM
CAMPER S NAME: DUKE SUMMER CAMP HEALTH FORM This form must be completed and signed by the camper s legal guardian. The information we ask you to provide is necessary in the event your child needs medical
be greater Buck Creek Camp $ Winter Camp Feb 27-Mar 1 Tubing - Zipline - Friends Speaker - Snow - Games Worship (forms due ASAP)
2015 Winter Camp Feb 27-Mar 1 Buck Creek Camp $119 (forms due ASAP) (scholarships available) be greater Tubing - Zipline - Friends Speaker - Snow - Games Worship payment accepted online - forms online
2017 Camper Application
Centennial Forest Environmental Education Programs 2017 Camper Application NAU Centennial Forest P.O. Box 15018 Flagstaff, AZ 86011 (928) 523-6727 Phone (928) 523-1080 Fax www.nau.edu/cfcamps Thank you
MEMBERSHIP APPLICATION
MEMBERSHIP APPLICATION How did you hear about the Y? Which facilities/programs do you plan to use? MEMBERSHIP TYPE YOU ARE SEEKING of Application Type of Membership PRIMARY MEMBER CONTACT INFORMATION Name
1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY
2017-18 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 07.19.17) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group
SCHOOL OF MUSICAL THEATRE
SCHOOL OF MUSICAL THEATRE (PERFORMANCE & PRODUCTION) // APPLICATION FORM // THE APPLICATION: PART 1: PERSONAL DETAILS PART 2: MEDICAL & HEALTH EVALUATION PART 3: REFERENCES PART 4: FINANCIAL RESPONSIBILITY
RENO POLICE DEPARTMENT RIDE-ALONG APPLICATION
RENO POLICE DEPARTMENT RIDE-ALONG APPLICATION Date you wish to ride-along First Choice Second Choice Shift you wish to ride-along Days (7:45 am) Swing (2:45 pm) Graveyard (9:45 pm) Name: Last First Middle
2018 Youth Academy Parent/ Guardian Agreement with NUS s Continuing Education
2018 Youth Academy Parent/ Guardian Agreement with NUS s Continuing Education Welcome to NSU Youth Academy! We are excited to have your child with us. In order to provide the best experience for our students
KATY,&TX& JULY&20921&
KATY,TX JULY20921 JUNE28 JULY5 Leadership Percussion ColorGuard Educator Updated2017907912 SYSTEMBLUEEDUCATION 1 WELCOME GREETINGSANDWELCOME! AllofuswithSystemBluewouldliketocongratulateyouonyourdecisiontojoinusinwhatwe
DAY CAMP ENROLLMENT FORM
2018-2019 DAY CAMP ENROLLMENT FORM *This camp program is a tuition for service program, based on confirmed enrollments and secured deposits. A $35 per camper, per session non-refundable and non-transferable
International Education Application
International Education Application Name of International Mission Team: Circle one: Personal Information: Spring Break / Summer Name: (last) (first) (middle) ID# Date of Birth: Country of Citizenship:
Initial Compliance Requirement Form
Page 1 INSTRUCTIONS Attention Before you create your account with Barry University School of Podiatric Medicine Immunization Tracking System, please be aware that your yearly subscription fee for using
PERSONAL DETAILS Please Print Clearly
Dear Volunteers, Thank you for your interest in the Albania Playground Build. We are excited for the opportunity to work alongside you for the kids of Albania. The need there is tremendous so we appreciate
Youth Camp REGISTRATION
Youth Camp REGISTRATION Parent #1 Name Home Phone Work Phone E-mail Address City State / ZIP Parent #2 Name Home Phone Work Phone E-mail Address City State / Zip 1. Camper s Name Age Gender Green and Gold
NORTHSIDE PRIMARY CARE
NORTHSIDE PRIMARY CARE Dr AAZRUM I. SYED, M.D. 11820 Northfall Lane Suite 1103 ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES **You may refuse to sign this acknowledgment** I, have received
Clayton State University Division of Student Affairs. Student Travel Agreement Form
Student Travel Agreement Form Assumption of Risk, Waiver of Liability, Covenant Not to Sue, & General Agreement (Important: Read Carefully before Signing) Each Student Must Complete, Read, and Sign Before
Therapy Group of Tucson, PLLC DEMOGRAPHICS PRIMARY INSURANCE INFORMATION SECONDARY INSURANCE INFORMATION N. Rosemont Drive, Ste.
Therapy Group of Tucson, PLLC 2260 N. Rosemont Drive, Ste. 100 Tucson AZ 85712 Phone: (520) 232-2021 Fax: (520) 232-2553 DEMOGRAPHICS Name: Age: Sex: male female Social Security #: - - Date of Birth: Street
YMCA of the Coastal Bend Summer Camp 2018 Enrollment Form
PARTICIPANT INFORMATION: YMCA of the Coastal Bend Summer Camp 2018 Enrollment Form Child (1) Name: Sex: [M] [F] (circle one) of birth: / / Camp Type/Location: YMCA Day Camp (Pre-K - 5 th ) Downtown YMCA
MCC Summer Camp Application
MCC Summer Camp Application Summer Camp Enrollment Guidelines Applicants are considered on a first-come, first-serve basis. Only complete application packets are considered. A complete application packet
Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment
PATIENT HEALTH INFORMATION The following information is requested to enable us to give the most consideration to your time and feelings. It is our sincere desire to give personal attention to each of our
Romanian Baptist Youth Assoc. July 17-22, 2017
Romanian Baptist Youth Assoc. July 17-22, 2017 CAMPER REGISTRATION FORM Please complete each page of this form and give it to your group leader. Campers without a completed registration form will not be
Thank you again for choosing CrossRoads for your care. We hope to exceed your expectations.
BELIEVE! COMMIT! ACHIEVE Dear New Patient, The staff at CrossRoads Physical Therapy and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level
Genesee Valley Bills Youth Football & Cheerleading Organization Registration Form
Genesee Valley Bills Youth Football & Cheerleading Organization Registration Form Participant Information Full Name: First Last Address: Street Address Apartment/Unit # City State ZIP Code Home Phone:
CITY OF PALM COAST YOUTH PARKS & RECREATION DEPARTMENT ADULT REGISTRATION FORM SENIOR
CITY OF PALM COAST YOUTH PARKS & RECREATION DEPARTMENT ADULT REGISTRATION FORM SENIOR Please print clearly. Completion of the registration process is required for each participant prior to program start
Summer & Short-Term Study Abroad Application Packet
Summer & Short-Term Study Abroad Application Packet Submit completed applications for faculty-led programs to the Program Leader. Submit completed applications for all other programs to the Office of International
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Last Name: Title: First Name: Middle Name: Nick Name: Marital Status: Address: City State Zip Code Home Phone: Work Phone: Cell Phone: SS#: DOB: Sex: Referring Dr: Referring
Thomas Yoon Dental Patient Information. Health Information
Patient Name: Thomas Yoon Dental Patient Information Last First MI (Preferred Name) Social Security #: Date of Birth: / / Gender: Male Female Marital status: Phone # (Home): (Cell): (Work): Ext: E-mail
Panama Legal & Medical Forms. In addition to the following documents, a scan of the participant s passport should be turned in by May 6 th.
Panama 2018 Legal & Medical Forms In addition to the following documents, a scan of the participant s passport should be turned in by May 6 th. GCC Panama Emergency Info JULY 26 th -AUGUST 3 rd, 2018
MEDICAL EXAMINATION UNIVERSITY HOUSING
MEDICAL EXAMINATION ALL BAND MEMBERS are required to have a physical examination by the doctor of your choice before you will be allowed to attend band rehearsals or perform with the band. No physical
Cooperative Youth Leadership Camp July 14 July 19
Cooperative Youth Leadership Camp July 14 July 19 Application Deadline: January 12, 2018 Please complete the attached application and return by mail or email to: United Power Inc. Attn: Julie Stewart 500
Waiver, Release of Liability, Indemnification and Consent to Medical Attention
Waiver, Release of Liability, Indemnification and Consent to Medical Attention 1. Voluntary Participation. I understand and confirm that my participation in the Program is voluntary. 2. Identification
FRANCIS HOWELL SCHOOL DISTRICT
FRANCIS HOWELL SCHOOL DISTRICT 4545 Central School Road St. Charles, MO 63304-7113 Phone: 636-851-4000 Fax: 636-851-4093 www.fhsdschools.org Dr. Jennifer Patterson Director of Student Services Phone: 636-851-4076
MEDICAL INFORMATION FORM
SONOMA STATE UNIVERSITY SUMMER BRIDGE PROGRAM MEDICAL INFORMATION FORM In the event of an illness or injury the medical staff will need the following information to properly treat you. If you are a minor,
PATIENT REGISTRATION / INFORMATION SHEET
PATIENT REGISTRATION / INFORMATION SHEET Name: LAST FIRST MIDDLE Date of Birth: Gender: M F Marital Status: Social Security Number: Email Address*: Street Address: City: State: Zip: Home Phone: Cell Phone:
Experience Europe 2016 College of Business and Communication Application - Due February 5,2016
- Due February 5,2016 Complete, sign, and submit this application along with your letter of intent to BYU-Idaho, College of Business and Communication, Smith 229, Rexburg, ID 83460-0810 Fax (208) 496-5414
Individual Waiver. PUEBLO RANGERS, 5v5 or 3v3 SOCCER LEAGUE AND TOURNAMENT WAIVER AND RELEASE OF LIABILITY
PUEBLO RANGERS Individual Waiver Soccer Club PUEBLO RANGERS, 5v5 or 3v3 SOCCER LEAGUE AND TOURNAMENT WAIVER AND RELEASE OF LIABILITY (MUST BE COMPLETED AND PRESENTED AT LEAST 30 MINUTES PRIOR TO YOUR FIRST
FARM 2 U JUNIOR MASTER GARDENER CAMP sponsored by Williamson County Master Gardener Association and the UT/TSU Williamson County Extension
FARM 2 U 2018 JUNIOR MASTER GARDENER CAMP sponsored by Williamson County Master Gardener Association and the UT/TSU Williamson County Extension JUNE 4th - 8th, 9am to 12:30pm at the Williamson County Ag
Madison Dentistry 424 Madison Avenue 15th Floor New York, NY (212) Patient Information. Health Information
Madison Dentistry 424 Madison Avenue 15th Floor (212)753-7400 Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Patient Information Birth Date: Family Status: Chart #: FOR OFFICE
GROUP TERM LIFE INSURANCE APPLICATION For Members of The American Optometric Association
1 2 Official Member No. Address: City, State, Zip: Member Information: Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes made. Member Request for Group
Study Abroad Service Learning Program - Student Applica on Packet
Interna onal Programs Chemeketa Community College Study Abroad Service Learning Program - Student Applica on Packet APPLICATION DEADLINES November 30, 2018 Belize Winter Term 2019 February 25, 2019 Oaxaca
After School Program Registration Form
2018-19 After School Program Registration Form Office Use Only Date registered: _ Staff: Please fill out this form entirely. If there are blanks it may slow down your child s enrollment process. If a line
CAMPER APPLICATION CAMP NEEDLES IN THE PINES The Eastern North Carolina Diabetes Camp. APPLICATION DEADLINE: Tuesday MAY 15, 2018
CAMPER APPLICATION CAMP NEEDLES IN THE PINES The Eastern North Carolina Diabetes Camp July 22 27, 2018 Sunday mid-afternoon through noon on Friday APPLICATION DEADLINE: Tuesday MAY 15, 2018 Please return
Confirmation of Participation
Confirmation of Participation studyabroad@ausm.community 773.583.7728 ausm.community 3460 W. Lawrence Ave Chicago, IL 60625 By submitting the last page of this Confirmation of Participation form you agree
For Participants in State University of New York Administered Overseas Academic Activities
AGREEMENT AND RELEASE FOR STUDY ABROAD STATE UNIVERSITY OF NEW YORK Overseas Academic Programs For Participants in State University of New York Administered Overseas Academic Activities To the Student: