Cascade Christian Schools Trip Release and Agreement

Size: px
Start display at page:

Download "Cascade Christian Schools Trip Release and Agreement"

Transcription

1 811 S21st St. SE Puyallup, WA Phone: Fax: Name of Trip Cascade Christian Schools Trip Release and Agreement I, (first and last name), a participant in Cascade Christian Schools I- Term program for 20, do voluntarily and without reservation and behalf of myself, my heirs and my estate, waive any and all claims of whatever nature for any injury, loss, damage, accident, delay, irregularity or expense arising from the use of any vehicles or services, strikes, war, weather, sickness, quarantine, government restrictions or regulations, or from any act or omission of any steamship, airline, railroad, bus, transportation, sight-seeing, hotel or any other service or transportation company, firm, individual or agency, or for any other cause whatsoever in connection therewith against Cascade Christian Schools, my school or college, or any staff member or chaperone accompanying this program, their heirs or their estate. I agree that Cascade Christian Schools reserves the right to make cancellations, changes or substitutions in the event of emergencies, or changed conditions such as wars, strikes, weather, government restrictions or acts of God. Cascade Christian Schools reserves the right to make alterations in part or in all of the entire program for which cancelled can be made only of those funds not actually used or committed. The amount of said funds, in each individual case, shall be determined by Cascade Christian Schools. Also, I agree that Cascade Christian Schools reserves the right to alter, prior to program department, the cost in order to meet unexpected changes in airfares, lodging and food rates, etc. The announced fee is based upon current tariffs which are subject to change. I have read the above Release and Agreement statements and understand the same. Signature of Participant Signature of Parent or Guardian (if under 18) Please Notarize Below State of, County of Before me, the undersigned, a Notary Public in and for said county and state on, 20, personally appeared the identical person who executed the within and foregoing instrument, and acknowledged to me that he/she/they executed the same as his/her/their free and voluntary act and deed, for the uses and purposes therein set forth. Given under my hand and seal of office the day and year above written. Notary Public Resides in My commission expires: / /

2 811 S21st St. SE Puyallup, WA Phone: Fax: Cascade Christian Schools Student Mission/Educational Trip DOCTOR S RELEASE FORM ***Only to be completed if you had to mark yes to any of the questions in Section II on the Medical Information Form*** This form must be completed, signed by the examining physician, and returned with the trip application to Cascade Christian Schools. (Please print or type) Name: Last First Middle Examining Physician: Telephone: Physician s Address: To the Examining Physician The above named student is applying to participate in a mission or educational trip for the dates of and his/her trip may involve the following activities: 1. Construction work: including lifting, kneeling, stretching, hammering and painting. 2. Community work: including walking and standing for extended periods of time. 3. Childcare: including physical contact with children. 4. Food preparation. 5. Sleeping on the floor, cots or air mattresses. Based on my physical examination I conclude the above named person: ( ) is able to participate in the physical activities described above. ( ) is not able to participate in the following physical activities as described above. Please list Physician s Signature Date

3 Cascade Christian High School POLICY FOR OBEDIENCE TO SCHOOL/LEADER RULES 2015 Trip Group Leader s Name: Traveler s name There is an expected level of behavior and personal responsibility that is involved with individuals participating in Cascade Christian sponsored trips. In order to participate in this trip, participants, their legal guardians and/or parents must agree to adhere to all school and group leader rules. Please be advised that if a participant chooses not to abide by these rules, they will be responsible for the financial cost that may be incurred to return the traveler home. If a problem arises that is serious enough in nature to warrant the participant s removal from the travel group, parents/guardians will be notified by phone. This removal decision will be made by the accompanying Group Leader and the Tour Director, after the student has had an opportunity to respond to any allegations. Depending on the severity of the infraction, the student may also be subjected to further discipline upon return home in accordance with school policy. By signing below, you acknowledge this statement and agree to the listed provisions; thus participating students and parents cannot legally hold the Group Leader or tour company responsible in any manner for the actions or poor choices made by the participant. As a parent/guardian you must sign this form acknowledging that all school rules apply while on this trip and that no travelers are permitted to consume alcohol of any kind for the duration of the trip. Travelers are subject to all local laws and any rules established by the Group Leader. Parent section I understand that the above named traveler must follow all school rules and may not consume alcohol while on tour even if permitted by the local culture. I further understand that if the traveler does not abide by this rule, school rules in general, or any other rules stipulated in the Explorica or Cascade Christian Release and Agreements that the Group Leader can send the traveler home at parent s expense. Parent/Guardian Name Parent/Guardian Signature Date Traveler section As the traveler, I agree to follow the above agreement made by my parent/guardian regarding trip rules and alcohol consumption on my Cascade Christian/Explorica tour. I fully understand the potential consequence of being sent home at my parent/guardian s expense if I do not comply with these rules, school rules, or any other rules outlined by my Group Leader. Student Name Traveler Signature Date

4 MEDICAL INFORMATION Student s Name In Case of emergency, please contact: 1. Name Home Phone Address, City, State, Zip 2. Name Home Phone Address, City, State, Zip Childhood Immunizations (These must be up-to-date. Please do not leave blank.) Yes No Type Year Administered Yes No Type Year Administered MMR Tetanus DPT Other Polio Please complete the following questions: Are you currently taking any prescribed medications? Yes No If yes, please specify the medication and the dosage: Are you currently using any non-prescription drugs on a regular basis such as antihistamines or sleeping aids? Yes No If yes, please specify: Have you ever received treatment or counseling for alcohol or drug abuse? Yes No If yes, please specify when and where: Are you presently under a physicians care for any illness? Yes No If yes, please explain: What was the date and who was the physician of your last physical exam? List all surgical operations or hospitalizations you have undergone: Operations and/or Illness Reason Date Name and address of hospital Name of Physician Remaining Affects Operations and/or Illness Reason Date Name and address of hospital Name of Physician Remaining Affects SECTION II ALL QUESTIONS MUST BE ANSWERED. MISREPRESENTATION WILL VOID YOUR ACCEPTANCE. In the past 5 years, have you been treated by a doctor for any of the following: (Every item must be checked.) Yes No Yes No Asthma or chronic wheezing Serious bodily injury Emphysema, lung or respiratory problems Parkinson s Disease Chronic, persistent cough or shortness of breath Tuberculosis Any skin disorder or disease other than acne Gall bladder stones or colic Diabetes or hypoglycemia (low blood sugar) Chronic/recurrent ear or eye problems Cancer Jaundice, cirrhosis, or other liver problems Impairment of hearing or vision, Menier s Disease, cataracts or glaucoma High blood pressure, heart murmurs or other cardiac problems Intestinal or bowel problems, colitis, diverticulitis, hemorrhoids, other rectal problems or bleeding Severe migraine headaches Albumin, blood or pus in the urine; painful or frequent urination, or kidney problems Persistent, recurring indigestion, stomach or duodenal ulcers Rheumatism, gout, arthritis or other forms of swollen painful joints Any test results indicating exposure to the Aids virus Chronic back pain, back injury, or surgery, sciatica, scoliosis or other bone or joint disorder Fainting spells, dizziness, convulsions, epilepsy or seizure disorder Severe knee injury or problems Cysts, tumors or growths or any kind, hernia or rupture Abnormality of reproductive systems, prostate problems Mental health counseling or psychiatric treatment Breast disorder, menstrual disorder or venereal disease Vein or circulatory trouble Severe allergic reactions to either food, medications, bee stings or any other kid of insect bits Anemia or other blood disorders Any other disease, deformity or disability not listed above Goiter, thyroid ailment, high or low metabolism **** PLEASE NOTE THE FOLLOWING: If you checked no to ALL the questions in Section II then you are NOT required to complete the provided doctors release form. If you checked yes to ANY of the questions in Section II you ARE required to: 1. Visit your Doctor 2. Have him/her complete and sign the doctor s release form provided **** YOUR ACCEPTANCE WILL BECOME VOID IF THESE STEPS ARE NOT FOLLOWED.

5 Consent for Medical Treatment: Release and Hold-Harmless for Travel Whereas, (my child) wish/es to be a member of a Cascade Christian Schools Student Ministry or Educational team which will be traveling to and staying in (state/country), and whereas, certain circumstances may occur resulting in (my child s/my) need for medical/dental care and treatment and further resulting in my inability to personally give consent for such care and treatment; therefore, in consideration of permission for (my child/myself) to participate in said mission or trip, I,, being of legal age, authorize Cascade Christian Schools or any agent of Cascade Christian Schools to act on (my child s/my) behalf should I be unable to do so, and to consent to reasonable medical/dental care and treatment including but not limited to diagnostic test, x-ray examination, anesthesia, surgery, or other procedures which may be deemed necessary for (my child s/my) medical well-being for the duration of the mission trip. This consent is given in advance of any specific diagnosis, treatment, surgery, or hospital care required, but is given to provide authorization and specific consent for medical/dental treatment and care in (my child s /my) behalf. Any consent by Cascade Christian Schools shall have the same force and effect as if I had personally given the consent. I certify I have personal health insurance with no territorial limitations, including foreign countries, which will provide coverage for (my child/me), during the duration of said mission. I understand no health plan is provided by Cascade Christian Schools. Company (Must provide proof of Medical insurance (Copy Attached). Policy Number I certify I am award that Cascade Christian Schools doesn t provide an insurance policy and I understand by not having a personal policy with no territorial limitations, I will personally be responsible for any extra cost that (my child/myself) may cause the team or Cascade Christian Schools. I am aware that serious illness requiring return by air ambulance, could cost more than $10,000. I agree I am solely responsible for any expenses which arise from (my child s/my) return by air ambulance, or other extraordinary means. I hereby release and hold harmless Cascade Christian Schools, it s officers, employees, and representatives/volunteers from all liability for personal injury, including death, as well as all property damage or loss arising out of (my child s/my) participation in this trip. I have read and understand the above information. This information I have given Cascade Christian Schools is accurate and true to the best of my knowledge. I also give Cascade Christian Schools the right to use my picture, voice, or testimony in any form of promotional or advertising materials. My enclosed signature signifies my approval of all limitations above. If you are under custody of both parents, both parent s signatures are required to be notarized. If you are under custody of one parent, the signature of the one whom has custody is required to be notarized. X Father s/guardian s Signature X Mother s/guardian s Signature X Student s Signature (This section to be filled out by a notary) State of, County of. Before me, the undersigned, a Notary Public in said county and state on, 20, personally appeared the identical person who executed the within and foregoing instrument and acknowledged to me that he/she executed the same as his/her free and voluntary act and deed, for the uses and purposes therein set forth. Given under my hand and seal of office the day and year written above. Notary Public Resides in Commission Expires Honor Code Recognizing Jesus as the author and finisher of my faith, and the Word of God as the supreme standard for all wisdom and knowledge, it is my aim to develop myself accordingly, realizing that as I seed first His kingdom and righteousness, all these things will be added unto me. It is my desire to develop myself as a servant and to seek opportunities to serve, realizing that love exalts and prefers others to self. I will endeavor to follow the will of God for my life and to exemplify Christ-like character through daily personal prayer, consistent study of the Word of God, and faithful group worship. I will endeavor to faithfully give heed to: th3e call God has on my life; to develop the gifts and abilities that God has given me. I will endeavor to bring glory and honor to the name of Jesus through my ministry and allow the love of the Spirit to flow through me. I will submit myself to the established leadership of Cascade Christian Schools and/or to any rules or regulations that may be adopted or changed from time to time. I realize my participation as a member is a privilege and a call from God, not a right. I purpose to give my best and to positively support the ministry of Cascade Christian Schools As part of this team, I take the Great Commission as a personal call on my life. It is my aim to spread the Good News and make the most of every opportunity to minister. Discipline Agreement The rules and regulations of Cascade Christian Schools are expressly designed to ensure the safety and well being of each team member and to main the high degree of Christian integrity required to minister effectively in cross-cultural settings. The enforcement of all aspects of these rules and regulations are the responsibility of the Cascade Christian Schools staff which includes the Trip Coordinator, and Adult Chaperones. Enforcement shall occur in a manner they feel is in accordance with Christian principles and the stated purpose of the project. We expect full cooperation from members (and parents if applicable) in disciplinary decisions made. The discipline committee reserves the right to send any team member home who shows disregard for the stated rules and regulations. The team member and/or his family are responsible for any cost involved in sending a team member home. The costs may include, but are not limited to, airfare, hotel room, and food. We have read the Rules and Regulations as stated and agree to abide by them. X X Student s Signature Date Parent s Signature Date

4-H HEALTHY LIVING RETREAT OCTOBER 13 TH -15 TH. Learn about careers & other opportunities in the healthy living field!

4-H HEALTHY LIVING RETREAT OCTOBER 13 TH -15 TH. Learn about careers & other opportunities in the healthy living field! Learn about careers & other opportunities in the healthy living field! Attend workshops on trending topics in Healthy Living! OCTOBER 13 TH -15 TH 4-H HEALTHY LIVING Take the 500 Mile Challenge, and participate

More information

NORTH CAROLINA 4-H VOLUNTEER APPLICATION

NORTH CAROLINA 4-H VOLUNTEER APPLICATION NORTH CAROLINA 4-H VOLUNTEER APPLICATION PERSONAL INFORMATION First Name: Middle Name: Last Name: Suffix: Preferred Name: Mailing Address: Mailing Address 2: City: State: Zip: Gender: Male Years in 4-H:

More information

University of South Alabama

University of South Alabama 2014 Concert Honor Wind Ensemble Schedule of Events Friday, December 5, 2014 o 3:00 PM- 4:00PM - Registration Open (Lobby of the Laidlaw Performing Arts Center) Accepted students will be assigned a part

More information

Partners In Ministry, Inc.

Partners In Ministry, Inc. Date: Partners In Ministry, Inc. Serving Richmond, Scotland, and Robeson Counties 12 Third Street Post Office Box 1621 Laurinburg, North Carolina 28352 Telephone 910-277-3355 www.pim-nc.org R.O.A.R. Work

More information

4-H Memorial Camp. Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information

4-H Memorial Camp. Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information 4-H Memorial Camp 2018 Summer Camp Registration Please use a separate registration for each camper or if you are attending multiple camp weeks. Camper Information Camper s First Name Male Female Camper

More information

TRINITY DENTAL CLINIC Medical History Form Date:

TRINITY DENTAL CLINIC Medical History Form Date: Page 1of 4 TRINITY DENTAL CLINIC Medical History Form Date: NAME DATE OF BIRTH ADDRESS CITY STATE ZIP PHONE NUMBERS PHYSICIAN DO WE HAVE PERMISSION TO LEAVE A MESSAGE AT THE PHONE NUMBERS LISTED ABOVE?

More information

November 17-19, 2017

November 17-19, 2017 NE District High School Youth Gathering 9th-12th grade vember 17-19, 2017 LaVista Conference Center Omaha, Nebraska $200/person Registration Deadline: October 1st (Scholarships available) Late registration

More information

DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group

DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group Date: NAME: AGE: DOB: Why are you here to see the doctor today? REFERRED BY: INSURANCE HEALTH GRADES INTERNET FRIENDS/RELATIVES PCP OTHER: Medications

More information

New Patient Registration Form NJR_NP_F100

New Patient Registration Form NJR_NP_F100 New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient

More information

The Home Doctor. Registration Checklist

The Home Doctor. Registration Checklist The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this

More information

LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W

LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:

More information

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU! PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF

More information

Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name

Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address

More information

Short Term Missionary Application

Short Term Missionary Application Short Term Missionary Application Calvary Chapel Oceanside 760-754-1234 ext.231 pallotto@calvaryoceanside.org Please answer all questions and return to the Missions Department. PERSONAL INFORMATION Please

More information

2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults

2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults 2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults Complete this form in ink answering all questions. Please print legibly The parent/guardian and camper both must sign this

More information

PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip

PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single

More information

The process has been designed to be user friendly and involves a few simple steps.

The process has been designed to be user friendly and involves a few simple steps. HOW DO I ENROLL A PATIENT WITH HOUSECALL MD? The process has been designed to be user friendly and involves a few simple steps. It is the patient s/family s/dpoa s/guardian s decision, if they want to

More information

Parma High School Washington, DC Trip 2018

Parma High School Washington, DC Trip 2018 Parma High School Washington, DC Trip 2018 Dear Parents: Please find the attached Parents Approval Form Educational Trips Overnight / Out-of-State / Out-of-the-Country. Parents are asked to neatly print

More information

John Jay College Study-Abroad Application

John Jay College Study-Abroad Application Office of International Studies & Programs John Jay College Study-Abroad Application Name: Last First Home Address: Street City State Zip Code Cell phone: ( _) Home phone: ( _) John Jay College/CUNY E-mail

More information

RETURNING STUDENT INFORMATION UPDATE

RETURNING STUDENT INFORMATION UPDATE ST. FRANCIS CATHOLIC SCHOOL Student Information Date: RETURNING STUDENT INFORMATION UPDATE Student Name Last First Middle I Nickname Birth Date Gender Grade Entering Birth Country Birth City Birth State

More information

Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) -

Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) - Wellesley Women s Care, P.C. PPG Thank you for taking the time to complete this form. We ask that you complete this entire form once a year or when you have any NEW information. PATIENT INFORMATION (Please

More information

Age: Birthdate: Date of Last Physical exam:

Age: Birthdate: Date of Last Physical exam: Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing

More information

ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security:

ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security: 716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone

More information

STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016

STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 The Clinic The Howard School 1192 Foster Street, NW Atlanta, Georgia 30318 Please complete this form and return with the other enrollment forms. Student

More information

U.S. Martial Arts Academy SUMMER CAMP 2015

U.S. Martial Arts Academy SUMMER CAMP 2015 U.S. Martial Arts Academy SUMMER CAMP 2015 3430 Oak Road Vineland, NJ 08361 Hours of operation 7:30am-5:30pm (Monday-Friday) Dates of Operation: Monday June 22nd thru Friday August 28th CLOSED WEEK OF

More information

Somerset Middle School Athletic Requirements

Somerset Middle School Athletic Requirements Somerset Middle School Athletic Requirements In order to be eligible (try out, practice, play) in the interscholastic sports programs at Somerset Middle School, the following must be completed and submitted:

More information

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name *SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code

More information

ST. CHARLES BORROMEO FOUNTAIN OF YOUTH YOUTH MINISTRY PROGRAM

ST. CHARLES BORROMEO FOUNTAIN OF YOUTH YOUTH MINISTRY PROGRAM YOUTH MINISTRY PROGRAM The St. Charles Borromeo Fountain of Youth is a unique Youth Ministry Program open to all young people in St. Charles Borromeo Church Parish in grades 5 12. Junior High Program is

More information

SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet

SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell

More information

YOUTH ACTIVITIES REGISTRATION FORM

YOUTH ACTIVITIES REGISTRATION FORM YOUTH ACTIVITIES REGISTRATION FORM REGISTRATION FOR: Baseball, Basketball, Cheerleading, Flag Football, Soccer, Softball, CHILD S NAME: AGE: SEX: HEIGHT (INCHES): WEIGHT (POUNDS): D.O.B.: (YYYY/MM/DD)

More information

August, GA 13. June 10-15

August, GA 13. June 10-15 August, GA 13 June 10-15 Jan. 16, 2013 Dear parents and students 6 th -12 th grade, Our excitement is growing for our missions opportunity this summer for all middle school and high school students. We

More information

Disney Band Trip 2017

Disney Band Trip 2017 Disney Band Trip 2017 Medical Forms Medicine Procedures Student Pledge The following 4 pages contain Student Medical Forms, which need to be filled out and returned by Friday, January 13, 2017. Please

More information

**** Medical Information/ Emergency Contacts/ Insurance/ Consent ****

**** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Arrival Departure Certification Level: **** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Camper s Name: Birthdate: Age: Parent/Legal Guardian/Adult Leader Name: Day Time Phone: Evening

More information

Superintendent s Regulation 4400-R Exhibit 1

Superintendent s Regulation 4400-R Exhibit 1 Superintendent s Regulation 4400-R Exhibit 1 School Field Trip Planning Form Instructions All information on this form must be completed before presenting the form for approval to the Principal, School

More information

January 27 th 7:30am- 7:00pm(ish)

January 27 th 7:30am- 7:00pm(ish) A Little Bit of Faith, A Little Bit of Fun! January 27 th 7:30am- 7:00pm(ish) $25 for the Day! Teens are invited to our Winter Trip for a Mini-Retreat, visit the Gonzaga campus, and enjoy some Laser Tag

More information

Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.

Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays. Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints

More information

Dodge. County. Schools

Dodge. County. Schools Welcome to the Dodge School Based Health Clinic. Dodge Board of Education and Dodge Connection-Communities In of Dodge, Inc. are continuing to move forward with our goal of serving the children and families

More information

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#: Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married

More information

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY 2016-17 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 08.01.16) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group

More information

YOUTH ACTIVITIES REGISTRATION FORM

YOUTH ACTIVITIES REGISTRATION FORM YOUTH ACTIVITIES REGISTRATION FORM REGISTRATION FOR: Baseball, Basketball, Cheerleading, Flag Football, Soccer, Softball, CHILD S NAME: AGE: SEX: HEIGHT (INCHES): WEIGHT (POUNDS): D.O.B.: (YYYY/MM/DD)

More information

WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you

WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:

More information

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred

More information

Independent Wellness Center 1000 W. Apache Trail, Suite #108, Apache Junction, AZ Phone# Fax #

Independent Wellness Center 1000 W. Apache Trail, Suite #108, Apache Junction, AZ Phone# Fax # PATIENT INTAKE Welcome t o Independent Wellness Center. In order to provide you with the best health care and assist you with other details of our clinic, we have provided the following information. We

More information

Application. For The. Tyler Police Department Law Enforcement Explorer Program

Application. For The. Tyler Police Department Law Enforcement Explorer Program Application For The Tyler Police Department Law Enforcement Explorer Program Attached are the forms that are required to be completed to be admitted into the Law Enforcement Explorer Program at the Tyler

More information

May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female

May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female 1 Health Information and Health History Patient Name: Gender: Male Female Marital Status: (Circle one) M S D W Other: Date of Birth / / Spouse Name: How many children: Patient Social Security Number: -

More information

Frontiersmen Camping Fellowship

Frontiersmen Camping Fellowship Explorer Territory North Star Chapter Frontiersmen Camping Fellowship Application for Membership (Please Print Legibly) Print Name: Phone: (First) (Middle) (Last) Address: E-Mail: Tee-Shirt Size Age: Birthday:

More information

HIGHLAND MEDICAL INFORMATION FORM

HIGHLAND MEDICAL INFORMATION FORM HIGHLAND MEDICAL INFORMATION FORM TODAY S DATE: SESSION NAME SESSION DATE Having adequate information about your child is crucial to our ability to provide a supportive environment. We rely on you to tell

More information

RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria

RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, 2015 Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria February, 2015 Dear Parents: After several years of 7 th graders

More information

ZooCrew Registration Packet Summer ZooCrew

ZooCrew Registration Packet Summer ZooCrew Summer ZooCrew Check the weeks you would like to sign your child(ren) up for ZooCrew: 4 & 5 year olds* Week of 7/18 In My Backyard Week of 8/1 Once Upon a Story Week of 8/15 Where the Wild Things Are 6

More information

To begin the application process, please complete the enclosed application and bring it with you to one of our weekly meetings.

To begin the application process, please complete the enclosed application and bring it with you to one of our weekly meetings. Dear Explorer Applicant, We are pleased that you have shown interest in the Miramar Police Department Explorer Program. The Explorer program is the best program that young men and women can become involved

More information

Community Life Center

Community Life Center Community Life Center- 2018-2019 Page 2 of 6 MEGA SPORTS CAMP- Waiver & Release Forms Effective Dates: January 1, 2018 January 1, 2019 CHILD S INFORMATION Name Grade Age DOB Male/Female Nickname School:

More information

SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet

SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell

More information

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission: Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment

More information

12111 NE First Street, Bellevue, Washington / P.O. Box 90010, Bellevue, Washington

12111 NE First Street, Bellevue, Washington / P.O. Box 90010, Bellevue, Washington Dear Parents/Guardians, January 18, 2017 Thank you for allowing your student to attend the SHOUT Experience. On Tuesday, March 28, 2017 the Bellevue School District will be hosting a leadership experience

More information

Patient s Legal Name: Preferred Name: First Middle Last

Patient s Legal Name: Preferred Name: First Middle Last Douglas County Dental Clinic Patient Registration Revised August 2016 We REQUIRE A Parent, Guardian, Or Other Legally Responsible Party To Complete & Sign all forms. Please provide a photo ID, Proof of

More information

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #: 5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:

More information

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial: Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -

More information

INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE

INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE All families are required to complete and submit ALL pages of this Health Form Package for their student

More information

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial: Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -

More information

East Baton Rouge Parish Junior Deputy

East Baton Rouge Parish Junior Deputy East Baton Rouge Parish Junior Deputy 2018 Application Packet Sheriff Sid J. Gautreaux, III Captain Randy M. Aguillard Program Director raguillard@ebrso.org Junior Deputy Membership Rules All members of

More information

2017 Medi-Slim Weight Loss Patient Information Form

2017 Medi-Slim Weight Loss Patient Information Form Medi-Slim Weight Loss Patient Information Form Patient Name (Last) (First) (MI) Name you prefer to be called: Patient Address: City:_ State Zip Phone number you would prefer us to use: May we email you?

More information

ABC MEDICAL PATIENT REGISTRATION FORM

ABC MEDICAL PATIENT REGISTRATION FORM ABC MEDICAL PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name First Name of Birth Gender Social Security Number Address City State Zip Code Home Phone Cell Phone Work Phone Race: (if you are multiracial

More information

Building Relationships with God, Youth and our Neighbor

Building Relationships with God, Youth and our Neighbor What: Who: Recognize that our neighbor is someone as worthy of God s love as I 2014 Theme Being Jesus Rejoicing and Sharing God s Love with the World John 3:16-18 / 2 Corinthians 13:11-13 Mission Statement

More information

Patient Communication Request

Patient Communication Request Patient Communication Request Name: Date of Birth: Address: ZIP: Home Phone: Work Phone: Cell Phone: E-mail address: It is the policy of Capstone Family Practice to contact patients for any lab results.

More information

Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801

Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801 How did you hear of our office? New Patient Registration SECTION 1: PATIENT INFORMATION Patient Name: M / F Date of Birth: Address: City: State: Zip Code: SECTION 2: PARENT / GUARDIAN / INSURANCE Name:

More information

August 4 -August 7, 2016

August 4 -August 7, 2016 Minnesota District Royal Rangers DISCOVERY LEADERSHIP TRAINING CAMP THE WOODS AT LAKE PLACID PILLAGER, MN August 4 -August 7, 2016 PURPOSE OF THIS CAMP Discovery Training Camp will provide boys with training

More information

Glastonbury Family YMCA. CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET

Glastonbury Family YMCA. CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET 2018 Glastonbury Family YMCA CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET CAMP LOCATION 30 High Street South Glastonbury, CT 06073 860-541-1812 STEP STEP one REGISTRATION Done online,

More information

Ambassador Program Application Packet

Ambassador Program Application Packet Ambassador Program Application Packet Thank you for your interest in becoming an Ambassador at Centinela Hospital Medical Center. Please complete the attached forms and then contact the Centinela Hospital

More information

Counselor Application 2018 July 9 th 13 th

Counselor Application 2018 July 9 th 13 th Counselor Application 2018 July 9 th 13 th Name Address City State & Zip Home Phone Cell Phone E-mail address Male Female Birth Date (mm/dd/yy) Age (at camp) Emergency Contact Name Phone Relation to Camper

More information

ALFRED ALINGU, MD INTERNAL MEDICINE

ALFRED ALINGU, MD INTERNAL MEDICINE Name Date of Birth Social Security Number Marital Status Address City State Zip Code Home Phone Cell Phone E-mail Address Pharmacy Name Pharmacy Phone Number Emergency Contact Phone Number Relationship

More information

Social Security Number: Employment Status: Employed Unemployed Address: Student Retired

Social Security Number: Employment Status: Employed Unemployed  Address: Student Retired Please complete all forms fully and to the best of your ability. If something does not apply to you please write N/A in the field. Patient Demographics: Name: Sex: Male Female Address: Apt: City: Marital

More information

Male Female Mailing Address: Apt. #: City: State: Zip Code:

Male Female Mailing Address: Apt. #: City: State: Zip Code: Patients ame: (Last, First, MI): DOB: SS: Circle One: / / Male Female Mailing Address: Apt. #: City: State: Zip Code: Driver s Lic or ID #: How would you like to be contacted for appointment reminders?

More information

Patients Name. Insurance policy holders name and Social security number. Address. Home Phone number. Work Phone Number

Patients Name. Insurance policy holders name and Social security number. Address. Home Phone number. Work Phone Number Patient Registration Form Print out this form and also the Health History Form. Bring both fully completed forms and your insurance card with you and give them to our staff as you check in for your appointment.

More information

City of Houston, Alaska Fire Department

City of Houston, Alaska Fire Department Welcome! This membership application is required if you want to join Houston. By picking this up, you have demonstrated an interest in joining the department and serving your community, which is greatly

More information

New Patient Paperwork

New Patient Paperwork Your Vision Is Our Focus New Patient Paperwork Dear Patient, Please fill out all of the following pages, and bring them with you to your scheduled appointment time. If you have questions regarding your

More information

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email

More information

2018 INDIANA COUNTY CAMP CADET APPLICATION

2018 INDIANA COUNTY CAMP CADET APPLICATION 2018 INDIANA COUNTY CAMP CADET APPLICATION CAMP SEPH MACK, BSA SUNDAY, AUGUST 5 TH - SATURDAY, AUGUST 11 TH, 2018 INDIANA COUNTY CAMP CADET, INC. 4221 ROUTE 286 HIGHWAY WEST INDIANA, PA 15701 PHONE: 724-357-1960

More information

Nicaragua Mission Trip: April 15-24, 2016

Nicaragua Mission Trip: April 15-24, 2016 American Baptist Churches of New York State & American Baptist Churches of Pennsylvania and Delaware Nicaragua Mission Trip: April 15-24, 2016 Part 1: Mission Trip Application: Cost: $1,750 Please Make

More information

We ll meet in the Youth Room at 2:30 p.m. and we ll return by 6:30 p.m. (depending on traffic)! For students in grades 7-12.

We ll meet in the Youth Room at 2:30 p.m. and we ll return by 6:30 p.m. (depending on traffic)! For students in grades 7-12. For I was hungry and your gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me. Matthew 25:35 The Dallas Life Foundation is a Christian based homeless shelter

More information

Welcome to Mid-State Health Center. Our Promise to You. Locations and Hours. After-Hours Access

Welcome to Mid-State Health Center. Our Promise to You. Locations and Hours. After-Hours Access 101 Boulder Point Drive, Suite 1 Plymouth, NH 03264 603-536-4000 www.midstatehealth.org Welcome to Mid-State Health Center Mid-State Health Center looks forward to working with you and your family. Your

More information

Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)

Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs

More information

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic needs. Please fill out this form as completely as possible. If you have any questions or concerns,

More information

Health History and Examination Form for Children, Youth and Adults Attending Camps

Health History and Examination Form for Children, Youth and Adults Attending Camps Health History and Examination Form for Children, Youth and Adults Attending Camps Suggested for resident camp use. Developed and approved by American Camping Association American Academy of Pediatrics

More information

Sage Medical Center New Patient Forms

Sage Medical Center New Patient Forms Sage Medical Center New Patient Forms Patient Name: DOB: Providers and Suppliers of Your Medical Care: Please list all providers and suppliers of your medical care such as primary care physicians, specialty

More information

Dr. Ian C. MacIntyre

Dr. Ian C. MacIntyre coburg dentistryinc.bsc, DDS Patient Information Dr. Ian C. MacIntyre Name: DOB: (dd/mm/yyyy) / / Telephone: home cell work email: preferred contact method: Address: Street city province postal code Healthcard:

More information

PATIENT INFORMATION FORM

PATIENT INFORMATION FORM PATIENT INFORMATION FORM Name: E-Mail: New Patient? Previous Patient? Previous name if different: Age: Date of Birth: Social Security #: Sex: Female Male Marital Status: S M W D Home Address: City: State:

More information

Please review the following list of medications and mark the ones for which you consent:

Please review the following list of medications and mark the ones for which you consent: MONTGOMERY COUNTY SCHOOL HEALTH UNIT CONSENT FOR SERVICES 20 Student Name: Grade: School: The School Health Unit will provide care for all students. This includes, but is not limited to, illness/injury

More information

Patient Registration Form

Patient Registration Form Patient Registration Form Please Complete the Following Information-Thank You Patient Information: Name: Last First MI Address: City: State: Zip: Home Telephone: Work Telephone: Best to Reach? Home? Work?

More information

NOTE: WE REQUEST THAT PARISHES AND SCHOOLS DO NOT USE THE RALLY AS A SUBSTITUTE FOR A CONFIRMATION RETREAT.

NOTE: WE REQUEST THAT PARISHES AND SCHOOLS DO NOT USE THE RALLY AS A SUBSTITUTE FOR A CONFIRMATION RETREAT. M E M O TO: FROM: CYMs, DREs and Middle School/Jr. High Principals Clare Kolenda, Middle School Youth Rally Coordinator Brian Flynn, Office of Youth Ministry DATE: January, 2018 RE: Middle School Youth

More information

Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens.

Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens. Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens. Who do we play? Other Youth Ministries from the Dallas Diocese When do we play?

More information

Louis R. Vita, D.D.S., F.A.G.D. 991 Van Houten Avenue Clifton, NJ Phone:

Louis R. Vita, D.D.S., F.A.G.D. 991 Van Houten Avenue Clifton, NJ Phone: Louis R. Vita, D.D.S., F.A.G.D. 991 Van Houten Avenue Clifton, NJ 07013 Phone: 973-777-1933 Fax: 973-777-4727 Email: Vitaoffice991@gmail.com Website: DrLouisVita.com We are pleased to welcome you to our

More information

4-H Shooting Sports Instructor

4-H Shooting Sports Instructor Training 4-H Shooting Sports Instructor Certification Training for 4-H Certified Adult Volunteers in the 4-H Shooting Sports Program Date: May 27-28, 2016 Location: Cost: State 4-H Office and Stillwater

More information

Hanover Township Public Schools Memorial Junior School 61 Highland Avenue Whippany, New Jersey 07981

Hanover Township Public Schools Memorial Junior School 61 Highland Avenue Whippany, New Jersey 07981 Dear Future 6 th Grade Parents: Hanover Township Public Schools Memorial Junior School 61 Highland Avenue Whippany, New Jersey 07981 May 9, 2014 I would like to thank you for attending last night s Fifth

More information

BETHESDA DENTAL GROUP

BETHESDA DENTAL GROUP PLEASE COMPLETE ALLINFORMATION THAT APPLIES TO YOU - THANK YOU PATIENT LAST NAME: FIRST: INITIAL How did you hear about us? Whom may we thank for your referral? Date of Birth: Single: Married: Divorced:

More information

Welcome to Hawaii Women s Healthcare

Welcome to Hawaii Women s Healthcare Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you

More information

Entrance Case History (Please write or print clearly)

Entrance Case History (Please write or print clearly) Stony Brook Medical Park 2500 Nesconset Highway Suite 4-A Stony Brook, NY 11790 (631) 675-9000 Fax (631) 675-9002 www.naturalapproach.us Entrance Case History (Please write or print clearly) Today s Date

More information

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************

More information

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other.  Address Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In

More information

New Mexico Military Institute Medical Packet - Marshall Infirmary

New Mexico Military Institute Medical Packet - Marshall Infirmary New Mexico Military Institute Medical Packet - Marshall Infirmary Incoming Cadets and Parents: 1. Please complete the attached Medical Information, Medical History, and Insurance forms, and ask your physician

More information

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL 32789 407-647-1331 Name Date Email @ Please Circle One: Ethnicity: Hispanic or Latino American/White Not Hispanic or Latino Unknown

More information