PRE-K ENROLLMENT APPLICATION

Size: px
Start display at page:

Download "PRE-K ENROLLMENT APPLICATION"

Transcription

1 Student Name First Middle Last Date of Birth PRE-K ENROLLMENT APPLICATION Early Childhood Program Fill out this application if your student is applying to an Early Childhood School. Required Documents to Enroll: Proof of Birth Current Immunizations Proof of Parentage/Guardianship Parent/Guardian Photo ID Proof of Household Income 2 Proofs of Residency: 1) Lease, Mortgage, or Tax Receipt AND 2) Gas or Electricity Utility Bill* *Current utility bill only; disconnect/shut-off notices will not be accepted. Admissions Phone: (816) Fax: (816) Admissions Office: 2901 Troost Ave. Kansas City, MO admissions@kcpublicschools.org Notice of Non-Discrimination The Kansas City 33 School District does not discriminate on the basis of sex, race, religion, color, national origin, ancestry, age, disability, sexual orientation, gender identity, or any other factor prohibited by law in its programs and activities. If you believe you have been subject to discrimination or harassment, or if you have any inquiries regarding the District s non-discrimination policies, please contact the Anti-Discrimination and Harassment Coordinator at 2901 Troost Ave., Kansas City, Missouri 64109, or call (816)

2 Student Information Choose one ethnicity: Hispanic/Latino... Not Hispanic/Latino... Check all appropriate races (regardless of ethnicity): American Indian/Alaskan Native... Asian... Black/African American... White... Native Hawaiian/Other Pacific Islander... Does your child qualify for federal programs? To help determine whether your child qualifies for a federal program, please check Yes or No in response to the following questions. 1. Does the student speak a language other than English?... Yes No If YES, what language is spoken 2. Is there a language other than English spoken in the home?... Yes No 3. Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?... Yes No Explain if it is a similar reason: 4. Are you sharing or contributing to household expenses?... Yes No 5. Are you currently residing at a shelter, motel, hotel, in a car, or at a campsite because your home has been damaged or because of economic reasons?... Yes No 6. Are you currently living in or participating with a community based temporary housing arrangement?... Yes No 7. Does the parent/guardian work for the federal government?... Yes No 8. Has either parent, guardian, child or child s spouse been employed within the past three (3) years (or any of the aforementioned currently employed) in some form of temporary or seasonal agriculture work such as: planting or harvesting crops, transporting farm products to market, working on a dairy or catfish farm, feeding or processing poultry, beef or hogs, cutting firewood or logs to sell, gathering eggs or working in hatcheries?... Yes No 9. Is either parent or guardian on active duty or reserve military... Active Duty National Guard or Reserve Not Military Safe Schools Form Instructions: This form must be completed for all new students enrolling in the Kansas City Public Schools. Submitting false statements or information to a student s disciplinary history is defined as a Class B Misdemeanor. Students could face removal from school for submitting false statements and/or information regarding residency or disciplinary history. Please answer the following questions. An explanation must be provided if you answer yes to any of the questions below. 1. Is the student currently on long-term suspension ( days) or expulsion from any in-state or out-of-state school (i.e. public, alternative, private, charter, or parochial school) previously attended?... Yes No If yes, please explain the reason(s) for suspension or expulsion: 2. Please list all schools your child has attended within the past (24) twenty-four months. Please include each school s name, city and state in which they are located: By signing and submitting this form in support of my child s enrollment in the Kansas City Public Schools, I understand that it is a criminal offense (class B Misdemeanor-Section RSMo) to give false information concerning prior disciplinary actions taken against my child for an offense in violation of School Board policies relating to weapons, alcohol, drugs or the willful infliction of injury to another person. I acknowledge and accept responsibility for the consequences of submitting false statements or information for the purpose of enrollment. Parent/Guardian Signature: Date: / /

3 Health History Form Student Name: Date of Birth: / / Grade: Student ID: School: Age: Sex: M F Parent/Guardian Name: Home Phone: Cell Phone: Work Phone: Please attach a copy of current immunizations from the Physician or Clinic. Students will NOT be permitted to enroll without proof of state required immunizations. Medication: Does your student take medications? Yes No Diagnosis/Reason Medication Dose Time(s) Health Information: Physician s Name Phone: Date of Last Visit: Dentist s Name: Phone: Date of Last Visit: Hospital Preference Has your child had or does your child have any of the following illnesses or diseases? Age Date Age Date Chicken Pox... Yes No Mononucleosis... Yes No Fifth s Disease... Yes No Scarlet Fever... Yes No Hepatitis... Yes No Strep Infection... Yes No Meningitis... Yes No Other Contagious Disease... Yes No Allergies (food, medications, environment, animals, etc.)... Yes No Injuries/Accidents... Yes No Asthma... Yes No Mental/Emotional Problems... Yes No Attention Deficit/Hyperactive Disorder... Yes No Physical Limitations... Yes No Behavior Problems... Yes No Pneumonia... Yes No Bladder Problems... Yes No Rash/Birthmark/Scar... Yes No Bowel Problems... Yes No Seizure Disorder... Yes No Broken Bones... Yes No Speech Problems... Yes No Dental Problems... Yes No Surgery... Yes No Diabetes... Yes No Sutures/Stitches... Yes No Frequent Ear Infections... Yes No Tube Feeding... Yes No Head Injury/Concussion... Yes No Tubes in Ears... Yes No Hearing Problems... Yes No Vision Problems... Yes No Heart Problems/Murmur... Yes No Wears Glasses/Contacts... Yes No Hospitalizations (other than newborn)... Yes No Wheel Chair... Yes No Please explain yes answers here:

4 Health History Form (Cont.) Student Concerns: Do you have any concerns about your student s: Vision... Yes No Hearing... Yes No Attention Span... Yes No Emotional Development... Yes No Speech... Yes No Behavior... Yes No Ability to Learn... Yes No Physical Development... Yes No Please explain yes answers here: In Case of Emergency and Parent/Guardian cannot be reached: Contact #1 Name: Phone No.: Relationship: Contact #2 Name: Phone No.: Relationship: Verification: In case of illness or injury of my student, I understand the school will attempt to contact parents or guardians first. Then they will contact other persons I have listed - who are authorized to receive information, make certain medical decisions, and have my student released to their custody. If none is available, the school is authorized to make whatever arrangements are deemed necessary to maintain my student s health including, but not limited to, emergency medical treatment. I am the legal Parent/Guardian of this student: Yes No Initials: If you are not the legal Parent/Guardian of this student, state your relationship to this student: I verify that the information provided on this form is accurate and current. SIGNATURE of Parent/Guardian/Other PRINTED Name of Parent/Guardian/Other Date

5 MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION / BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE CHILD CARE ENROLLMENT FORM FACILITY/PROVIDER NAME ADMISSION DATE DISCHARGE DATE CHILD S NAME GENDER BIRTHDATE ADDRESS (STREET, CITY, STATE, ZIP CODE) IDENTIFYING INFORMATION MOTHER S/GUARDIAN S NAME ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE HOME TELEPHONE NUMBER CELL PHONE NUMBER ADDRESS EMPLOYER OR SCHOOL ATTEND EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE) FATHER S/GUARDIAN S NAME ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE WORK/SCHOOL SCHEDULE WORK TELEPHONE NUMBER HOME TELEPHONE NUMBER CELL PHONE NUMBER ADDRESS EMPLOYER OR SCHOOL ATTEND EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE) WORK/SCHOOL SCHEDULE WORK TELEPHONE NUMBER EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY (OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED. NAME RELATIONSHIP TO CHILD TELEPHONE NUMBERS (CELL, WORK, HOME) ADDRESS (STREET, CITY, STATE, ZIP CODE) NAME RELATIONSHIP TO CHILD TELEPHONE NUMBERS (CELL, WORK, HOME) ADDRESS (STREET, CITY, STATE, ZIP CODE) COMMENTS ON CHILD S DEVELOPMENT (PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS) CACFP REQUIREMENT RELATED CHILD YES NO HOW IS CHILD RELATED TO CHILD CARE PROVIDER? CHILD S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED CHECK HERE WHAT DAYS THE CHILD WILL ATTEND. WILL CHILD ATTEND: FULL TIME OR PART TIME WHAT TIME DOES YOUR CHILD USUALLY ARRIVE EACH DAY? CIRCLE AM OR PM WHAT TIME DOES YOUR CHILD USUALLY LEAVE EACH DAY? CIRCLE AM OR PM WRITE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL ATTENDANCE IN THIS SECTION INCLUDING SHIFT CHANGES. MONDAY AM PM AM PM TUESDAY AM PM AM PM WEDNESDAY AM PM AM PM THURSDAY AM PM AM PM FRIDAY AM PM AM PM SATURDAY AM PM AM PM SUNDAY AM PM AM PM MO (11-15) PLEASE ALSO COMPLETE PAGE 2 SCCR/CACFP PAGE 1

6 CACFP REQUIREMENT CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY BREAKFAST MORNING SNACK LUNCH AFTERNOON SNACK SUPPER EVENING SNACK NONE CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY NEW YEARS S DAY (JANUARY) MEMORIAL DAY (MAY) VETERANS DAY (NOVEMBER) MARTIN LUTHER KING JR. S BIRTHDAY (JANUARY) INDEPENDENCE DAY (JULY) ELECTION DAY (NOVEMBER) PRESIDENT S DAY (FEBRUARY) LABOR DAY (SEPTEMBER) THANKSGIVING (NOVEMBER) EASTER (MARCH/APRIL) COLUMBUS DAY (OCTOBER) CHRISTMAS DAY (DECEMBER) AUTHORIZATION FOR EMERGENCY MEDICAL CARE I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE. IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE TO CONTACT THE FOLLOWING: NAME NAME DAY CARE PROVIDER OR HOME PROVIDER PHYSICIAN OR CLINIC PREFERRED HOSPITAL TELEPHONE NUMBER TELEPHONE NUMBER ACKNOWLEDGEMENTS I HAVE RECEIVED A COPY OF THIS FACILITY S POLICIES PERTAINING TO THE A ADMISSION, CARE AND DISCHARGE OF CHILDREN. I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE B HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY FOR REVIEW. THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING C COMMUNICATION REGARDING MY CHILD S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS. WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE D ACCEPTED FOR CARE OR REMAIN IN CARE. I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I E WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS. I DO F DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS. I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED. I DO G DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD. I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY S SAFE H SLEEP POLICY WHEN ENROLLING A CHILD LESS THAN ONE (1) YEAR OF AGE. I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED I IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED. PARENT S/GUARDIAN S SIGNATURE DATE CACFP REQUIREMENT FIRST ANNUAL UPDATE PARENT/GUARDIAN SIGNATURE DATE SECOND ANNUAL UPDATE PARENT/GUARDIAN SIGNATURE DATE THIRD ANNUAL UPDATE PARENT/GUARDIAN SIGNATURE DATE MO (11-15) SCCR/CACFP PAGE 2

7 KCPS EDUCATIONAL SERVICES SUBSIDY APPLICATION COMPLETE ONE APPLICATION PER HOUSEHOLD PART 1. FOOD STAMP/TEMPORARY ASSISTANCE BENEFITS If any member of your household receives Food Stamps or Temporary Assistance, provide the name and case number for the person who receives the benefits below. Also complete Part 2, numbers 1, 2, and 3 for all students in the household. If no one receives benefits, fill out Part 2 completely. Name: Case Number: 0 0 PART 2. HOUSEHOLD INFORMATION 3. Name of school building Name of school building for each 2. Student child/student or ID (if indicate N/A if 1. Name list everyone in household applicable) not in school 4. Grade PART 3. HOMELESS, MIGRANT, OR RUNAWAY STUDENT 5. Check if a foster child legal responsibility of welfare agency or court 6. Gross income and how often it was received (weekly, every 2 weeks, 2x per month, monthly, yearly) Earnings from work before deductions Welfare, child support, alimony Pensions, retirement, social security, SSI, and VA benefits All other income Income How often Income How often Income How often Income How often If any student you are applying for is homeless, migrant, or a runaway contact the KCPS Homeless Liaison/Migrant Coordinator at Check if no Income PART 4. SIGNATURE (ADULT MUST SIGN) An adult household member must sign the application. If Part 2 is completed, the adult signing the application must also list his or her last four digits of their social security number or mark the I do not have a social security number box. (See Privacy Act Statement.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school may be eligible for certain federal funds based on the information I give. I understand that the school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose benefits, and I may be prosecuted. Sign here: Print name: Date: Address: City: Zip code: Phone number: Last 4 digits of social security number: * * * - * * - I do not have a social security number Privacy Act Statement. You do not have to provide the information on this form, but if you do not, we cannot determine your child s eligibility for additional benefits under state and federal programs. We will hold the information you provide as private and confidential to the extent required by law. However, we will share your information with various state and federal programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. Regardless of whether you provide the information on this form, all KCPS students will receive meals at no charge. Non- discrimination Statement. KCPS is committed to maintaining an educational environment that is free from discrimination and harassment in admission or access to, or treatment or employment in, its programs, services, activities and facilities. KCPS prohibits discrimination and harassment against employees, students or others on the basis of sex, race, religion, color, national origin, ancestry, age, disability or any other factor prohibited by law. Inquiries regarding the nondiscrimination policies should be directed to Kansas City Public Schools, Attention: Chief Legal Counsel, 1211 McGee, Kansas City, Missouri 64106; DO NOT FILL OUT THIS SECTION. THIS IS FOR SCHOOL USE ONLY. ANNUAL INCOME CONVERSION: WEEKLY X 52, EVERY 2 WEEKS X 26, TWICE A MONTH X 24, MONTHLY X 12 (USE ONLY IF MULTIPLE FREQUENCY) Food Stamps/Temporary Assistance Household size: Total income: Per: Week Every 2 Weeks Twice a Month Month Year Eligibility: Qualifies Does not Qualify Reason: Date withdrawn: Determining Official s Signature: Date Approved/Denied: Confirming Official s Signature (For verification purposes only): Date:

8 MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION CHILD MEDICAL EXAMINATION REPORT (INFANT/TODDLER/PRE-SCHOOL) IDENTIFYING INFORMATION CHILD S NAME BIRTHDATE CURRENT STATE OF HEALTH Based on my assessment of this child s medical history, current state of health and my physical examination of the child on / /, this child can participate in a child care program. This child has no special care needs unless specified below. (Date of medical examination must be within the last 12 months.) PHYSICIAN S INSTRUCTIONS FOR SPECIALIZED CARE Complete this section only if child requires special care at a child care facility, e.g. special diets, allergies, ear infections, convulsions, diabetes, asthma, behavior problems, hearing or visual impairment, etc. (Attach additional pages as needed.) SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER THE SUPERVISION OF A PHYSICIAN DATE PHYSICIAN S OR NURSE S NAME (PLEASE PRINT) NAME AND ADDRESS OF CLINIC, GROUP, PRACTICE OR OTHER (MAY USE STAMP.) IF NURSE IS SUPERVISED BY A PHYSICIAN, INDICATE PHYSICIAN S NAME (PLEASE PRINT.) TELEPHONE NUMBER MO (6-14) TO BE FILED IN CHILD S RECORD AT CHILD CARE FACILITY BCC-6A

Hospital Name. Medical Record Number: Hours/Days of Operation: Clinic: Physician: Contact Person / Title: Phone: Fax: Hours/Days of Operation:

Hospital Name. Medical Record Number: Hours/Days of Operation: Clinic: Physician: Contact Person / Title: Phone: Fax:   Hours/Days of Operation: Hospital Name City, State, Zip Code: Phone Numbers: Main Number: Emergency Room: Medical Record Number: Clinic: Hours/Days of Operation: Physician: Contact Person / Title: Phone: Fax: Email: Clinic: Hours/Days

More information

APPLICATION. Name (Last, First, MI): Address: City, State, & Zip Code: Home Telephone: Cell Telephone: Date of Birth: / /

APPLICATION. Name (Last, First, MI): Address: City, State, & Zip Code: Home Telephone: Cell Telephone: Date of Birth: / / Girls in Engineering Academy (GEA) July 10 August 4, 2017 APPLICATION A Summer Pre-Engineering Program for Middle School Girls Please print or type all information. Additional sheets may be attached if

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

Welcome To. School Information:

Welcome To. School Information: Welcome To School Information: School Address: 130 E. Brigham Road, Stansbury Park, UT 84074 School Phone: 435-833-9754 Fax: 435-833-9759 Principal: Shanz Leonelli 435-833-9754 sleonelli@tooeleschools.org

More information

Indiana Energy Assistance Program Application Part 1. Personal Information

Indiana Energy Assistance Program Application Part 1. Personal Information INSERT AGENCY LOGO 2017-2018 Indiana Energy Assistance Program Application Part 1. Personal Information Your Name Date of Birth First MI Last Social Security Number MM-DD-YYYY Current Home Address: Street

More information

YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT

YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT *This information will be used for verification and identification purposes only

More information

Additionally, the parent or legal guardian must provide the following documents upon registration of a new student:

Additionally, the parent or legal guardian must provide the following documents upon registration of a new student: Montgomery County Public Schools requires several documents upon registration of a new student. Below is a list of documents which may be downloaded and reviewed and/or completed by the parent or legal

More information

Application for Employment Related Day Care (ERDC) Program

Application for Employment Related Day Care (ERDC) Program Application for Employment Related Day Care (ERDC) Program Please read these instructions before filling out this application. Answer all questions. Do not write in the shaded areas. To contact our office

More information

Adult Health History

Adult Health History Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure

More information

Hope Academy of Public Service GENERAL STUDENT INFORMATION

Hope Academy of Public Service GENERAL STUDENT INFORMATION Hope Academy of Public Service GENERAL STUDENT INFORMATION First Name: Middle Name: Last Name: SSN: Current Grade: Birth date: Age: Gender: M or F Ethnicity (check one): Primary Race (check only one):

More information

ADMISSION INFORMATION CHECKLIST

ADMISSION INFORMATION CHECKLIST APPLICANT: ADMISSION INFORMATION CHECKLIST Below is a listing of information needed before scheduling the Pre-Admission Interdisciplinary meeting. NEED: 1. Release of Information 2. Fully Completed Application

More information

ADMISSION INFORMATION

ADMISSION INFORMATION Texas Dept of Family and Protective Services ADMISSION INFORMATION Form 2935 Aug 2010 / Pg 1 of 3 Operation Name The Stepping Stone Director s Name Ashley Stock Child s Full Name Child s of Birth Child

More information

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

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

4-H Enrollment Form. Name of 4-H Group/Unit: Member Name: First Middle Last. Address: Street Address City State Zip Code

4-H Enrollment Form. Name of 4-H Group/Unit: Member Name: First Middle Last. Address: Street Address City State Zip Code 4-H Enrollment Form Name of 4-H Group/Unit: Year: Member Name: First Middle Last Address: Phone:( ) Email: County: Gender*: q Male q Female Date of Birth: Grade: School Attending: If re-enrolling in 4-H,

More information

School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax:

School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax: School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE 19720 Phone: 324 5740 Fax: 324 5745 Dear Parents/Guardians: The William Penn School Based Health Center (SBHC) is a

More information

SAVE THE DATE! Discover the Leader in You! 4-H Conference

SAVE THE DATE! Discover the Leader in You! 4-H Conference SAVE THE DATE! Discover the Leader in You! 4-H Conference Dates & Locations South - February 17, 2018 10:00 AM-3:30 PM Gloucester County 4-H Office, 1200 N. Delsea Drive, Clayton North - March 17, 2018

More information

Teddy Forstmann Scholarship Program Application Instructions

Teddy Forstmann Scholarship Program Application Instructions 2015-2016 Application Instructions APPLICATION DEADLINE: FRIDAY, AUGUST 21, 2015,,. Applications postmarked AFTER this deadline may not be awarded. Please be sure to keep in contact regularly with your

More information

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION Thank you for your interest in Estes Park Medical Center. The mission of the Estes Park Medical Center is to make a positive difference in the health and wellbeing of all we serve. VOLUNTEER APPLICATION

More information

Network Security Specialist Course Selections (Grant Funded Tuition)

Network Security Specialist Course Selections (Grant Funded Tuition) COURSE SELECTION FORM Network Security TAACCCT INTERFACE Grant Fall 2014 Instructions: 1. Download application* and Course Selection Form to a USB drive or your personal computer 2. Fill out the grant

More information

Other submitted/received documentation (check all that apply): Current Immunizations Student Records Photo ID

Other submitted/received documentation (check all that apply): Current Immunizations Student Records Photo ID * *An enrollment can include either a new enrollment, a re-enrollment or a transfer from other Pittsburgh Public Schools building. PPS Personnel ONLY: Date Received: Date Processed: Student ID#: School

More information

Wyoming County Employment Application

Wyoming County Employment Application Wyoming County Employment Application We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital, veteran, or any other legally

More information

HOME ENERGY ASSISTANCE/UNIVERSAL SERVICE FUND (USF) AND WEATHERIZATION PROGRAM APPLICATION

HOME ENERGY ASSISTANCE/UNIVERSAL SERVICE FUND (USF) AND WEATHERIZATION PROGRAM APPLICATION Applicant Address HOME ENERGY ASSISTANCE/UNIVERSAL SERVICE FUND (USF) AND WEATHERIZATION PROGRAM APPLICATION Last Name 01 First Name 02 MI 03 _ Application Date: / / 10 Mailing address Street Address 04

More information

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Today date: HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Patient Full Name: Of Birth: Street: City: Zip Code:

More information

Name: Last First Middle. Date of Birth: / / Place of Birth: Current Address: Street City State Zip # of years

Name: Last First Middle. Date of Birth: / / Place of Birth: Current Address: Street City State Zip # of years The Arc Baltimore Application for Services (Please Print or Type) of Application: Check program(s) for which application is being submitted. Please print clearly when completing the application. ADULT

More information

Student Participant Health Form

Student Participant Health Form Participant Name: Male Female Birth Age on arrival at program Month/Day/Year To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. 1. 2. Complete pages

More information

School Based Health Consent for Services Grace Community Health Center, Inc.

School Based Health Consent for Services Grace Community Health Center, Inc. School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by

More information

10689 N. 99 th Ave., Peoria, AZ Phone: (623) Fax: (623) Application for Employment. Employment Desired

10689 N. 99 th Ave., Peoria, AZ Phone: (623) Fax: (623) Application for Employment. Employment Desired 10689 N. 99 th Ave., Peoria, AZ 85345 Phone: (623) 977-3977 Fax: (623) 977-5067 Application for Employment Personal Information *Please do not leave any spaces blank. Write N/A if not applicable* : Name:

More information

Volunteer Application

Volunteer Application Volunteer Application Applicant Information First Name: Middle Initial: Last Name: Address: City: State: Zip: Home Phone: Cell Phone: Email: Occupation: Special Skills: Volunteer Preferences Have you previously

More information

2018 Alexandria 4-H Summer Day Camp- Lights, Camera Cooking Registration Form

2018 Alexandria 4-H Summer Day Camp- Lights, Camera Cooking Registration Form 2018 Alexandria 4-H Summer Day Camp- Lights, Camera Cooking Registration Form First Name: Last Name: Address: City: Birthdate: Parent/Guardian Name: Primary Phone: State: Age as of Sept 30: Email: Alt.

More information

INSTRUCTIONS FOR CACFP - CHILD CARE CENTER REVIEW

INSTRUCTIONS FOR CACFP - CHILD CARE CENTER REVIEW INSTRUCTIONS FOR CACFP - CHILD CARE CENTER REVIEW Sponsoring organizations use this form, or alternate, to determine if participating sites are in compliance with the Child and Adult Care Food Program

More information

Adding an Online Meal Application

Adding an Online Meal Application Adding an Online Meal Application When you begin adding an application for free and reduced-price meals, instructions are listed at the top of each page. You can use the links in the column on the left-hand

More information

Applicant Information

Applicant Information POSITION APPLIED FOR: DATE City of Coos Bay at your service Applicant Information NAME Last First Middle ADDRESS CITY STATE ZIP TELEPHONE Home Message Work Cellular Best time to call: At work At home May

More information

Summer Day Camp Registration 2018 Pierce County School Based Day Camps YMCA OF PIERCE AND KITSAP COUNTIES

Summer Day Camp Registration 2018 Pierce County School Based Day Camps YMCA OF PIERCE AND KITSAP COUNTIES Summer Day Camp Registration 2018 Pierce County School Based Day Camps YMCA OF PIERCE AND KITSAP COUNTIES Completed registration is due the Wednesday prior to first day of camp. Return registration to

More information

The Arc of Vigo County 11 Cherry St. Terre Haute, IN (812) EOE Provider Application

The Arc of Vigo County 11 Cherry St. Terre Haute, IN (812) EOE Provider Application 1 The Arc of Vigo County 11 Cherry St. Terre Haute, IN 47807 (812) 232-4112 EOE Provider Application In compliance with Federal and State Equal Opportunity Employment Laws, qualified applicants will be

More information

Rice County HRA Bridges Application

Rice County HRA Bridges Application Rice County HRA Bridges Application This application is for the Bridges Program only. Read the instructions for each section and answer all required questions. Incomplete applications will slow processing

More information

Welcome to The Brevard Health Alliance

Welcome to The Brevard Health Alliance Welcome to The Brevard Health Alliance The Brevard Health Alliance, Inc. (BHA) is a Community Health Center serving Brevard County residents providing comprehensive medical services to all residents. It

More information

RESOURCE CENTER ASSISTANCE APPLICATION

RESOURCE CENTER ASSISTANCE APPLICATION RESOURCE CENTER ASSISTANCE APPLICATION Please clearly print all information on application. Complete the application in blue/black ink. Do not leave any blank spaces enter 0 or N/A if it does not apply.

More information

Summer College Prep Program July 7 th, 2014 July 25 th, 2014

Summer College Prep Program July 7 th, 2014 July 25 th, 2014 Summer College Prep Program July 7 th, 2014 July 25 th, 2014 11 th graders entering 12 th grade in the fall of 2014 Application Requirements 1. Student must complete STEP College Prep Summer Program application.

More information

North Carolina Extension Master Gardener Volunteer Application Guilford County

North Carolina Extension Master Gardener Volunteer Application Guilford County North Carolina Extension Master Gardener Volunteer Application Guilford County Please return all seven (7) pages of the completed Application to: 3309 Burlington Rd, Greensboro, NC 27405 GENERAL INFORMATION

More information

Middletown Summer Youth Employment Program. Summer 2018

Middletown Summer Youth Employment Program. Summer 2018 Middletown Summer Youth Employment Program Summer 2018 Summer 2018-Youth @ Work Middletown Summer Youth Employment Program IMPORTANT PROGRAM NOTES Applications will be available on Monday, April 2, 2018

More information

YMCA Before and After School Care School Year YMCA OF PIERCE AND KITSAP COUNTIES

YMCA Before and After School Care School Year YMCA OF PIERCE AND KITSAP COUNTIES PARENT INFORMATION PAGE YMCA Before and After School Care 2018-2019 School Year YMCA OF PIERCE AND KITSAP COUNTIES All fields must be completed for TACOMA registration PUBLIC packet to SCHOOLS be considered

More information

BID SHSGA CACFP CONTRACT #03309 FY2015 ADVERTISEMENT FOR FOOD PROCUREMENT FOR KIDS CAFÉ PROGRAM

BID SHSGA CACFP CONTRACT #03309 FY2015 ADVERTISEMENT FOR FOOD PROCUREMENT FOR KIDS CAFÉ PROGRAM BID SHSGA CACFP CONTRACT #03309 FY2015 ADVERTISEMENT FOR FOOD PROCUREMENT FOR KIDS CAFÉ PROGRAM Second Harvest of South Georgia, Inc. ( SHSGA ) is accepting Sealed Bids from qualified food vendors for

More information

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax: Dear Parents/Guardians: School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE 19807 Phone: 651-2100 Fax: 651-2111 The Wilmington Charter/Cab Calloway

More information

HPNAP FOOD GRANT APPLICATION SOUP KITCHENS

HPNAP FOOD GRANT APPLICATION SOUP KITCHENS HPNAP FOOD GRANT APPLICATION SOUP KITCHENS Grant Overview The HPNAP Food Grant provides eligible food pantries, soup kitchens, and emergency shelters with lines of credit at the Regional Food Bank of Northeastern

More information

CAMP AT THE EASTWARD A Youth Ministry of Mission at the Eastward

CAMP AT THE EASTWARD A Youth Ministry of Mission at the Eastward CAMP AT THE EASTWARD A Youth Ministry of Mission at the Eastward Dear Camper and Family, We are welcoming some changes to the camp schedule this year! In an effort to allow our dedicated work groups to

More information

Roosevelt Care Center. Volunteer Service Application

Roosevelt Care Center. Volunteer Service Application Volunteer Service Application Name : : City, State, Zip Code: Home phone #: Cell phone# In Case of Emergency, please notify: Phone # Relationship: of last PPD (Tuberculosis skin test) Have you had: Mumps

More information

Pitt County 2017 4-H Summer Fun Registration Programs are open to the public and filled on a first- come, first- served basis. Fees are NONREFUNDABLE unless the camp is cancelled. Participants are required

More information

Registration Guidelines

Registration Guidelines Registration Guidelines 2018 2019 Providing a Quality Education in a Christian Atmosphere Registration for 2018-2019 In order to reserve your child s spot in a class at Hillcrest School for the coming

More information

Candidates failing to include ALL required documentation will be disqualified.

Candidates failing to include ALL required documentation will be disqualified. To All Police Officer Candidates: Thank you for your interest in employment with the City of South St. Paul! We anticipate hiring two officers immediately with additional opening(s) occurring during the

More information

Every Friday starting April 21, 2017 (2:00pm 4:00pm)

Every Friday starting April 21, 2017 (2:00pm 4:00pm) Summer Youth Employment & Training Program (SYEP) 2017 SYEP It is an employment and training program, which offers income eligible New London area youth, ages 14-21 (must be 14 by 7/1/17), the opportunity

More information

Initial Eligibility Application WIOA / GAP / PACE

Initial Eligibility Application WIOA / GAP / PACE STAFF NLY Trade Act Petition Number: Initial Eligibility Application WIA / GAP / PACE What program are you applying for? WIA GAP PACE I. GENERAL INFRMATIN Name (Last, First, Middle Initial): Social Security

More information

St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101

St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101 St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101 APPLICATION FOR RENTAL A. Applicant Information DATE Catholic Charities is required to verify that all tenants of the St. Vincent Apartments

More information

Back-Up Care Advantage Program Registration Materials

Back-Up Care Advantage Program Registration Materials Registration Materials Dear Parent, Welcome to the Back-Up Care Advantage Program! An important part of preparing for a day of back-up care is ensuring that your care provider will have the information

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

Crossover Healthcare Ministry Financial Application

Crossover Healthcare Ministry Financial Application Crossover Healthcare Ministry Financial Application Are you PREGNANT? HIV positive? Recently been in the ER or HOSPITAL? If YES, please speak with a staff member immediately. *New Patients We are unfortunately

More information

Developmental Pediatrics of Central Jersey

Developmental Pediatrics of Central Jersey PATIENT INFORMATION: CLIENT INFORMATION Date: Name: (Last) (First) (M.I.) Birthdate: Sex: Race: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email Address: Regarding the office staff or physician

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

Cooperative Extension Service Daviess County 4800A New Hartford Road Owensboro KY Fax: extension.ca.uky.

Cooperative Extension Service Daviess County 4800A New Hartford Road Owensboro KY Fax: extension.ca.uky. Cooperative Extension Service Daviess County 4800A New Hartford Road Owensboro KY 42303 270-685-8480 Fax: 270-685-3276 extension.ca.uky.edu Win A Chicken Coop! Girls In Agriculture Leadership Academy

More information

South Carolina Department of Social Services Emergency Shelters Program (ESP) APPLICATION FOR PARTICIPATION

South Carolina Department of Social Services Emergency Shelters Program (ESP) APPLICATION FOR PARTICIPATION South Carolina Department of Social Services Emergency Shelters Program (ESP) APPLICATION FOR PARTICIPATION Agreement Number: Federal Identification Number: Name and Address of Organization 1. Name: Telephone:

More information

Whom it May Concern Respite Application

Whom it May Concern Respite Application To: Subject: Whom it May Concern Respite Application Enclosed please find an application for Respite Services. Please be sure to complete the following forms: The Arc Northern Chesapeake Region application

More information

Freya's Cat Rescue. a 501(c)(3) non-profit organization P. O. Box 264 Tennent, New Jersey Application for Volunteers and Interns

Freya's Cat Rescue. a 501(c)(3) non-profit organization P. O. Box 264 Tennent, New Jersey Application for Volunteers and Interns 1 TM a 501(c)(3) non-profit organization P. O. Box 264 Tennent, New Jersey 07763 Application for Volunteers and Interns Today s Date: Personal Information Name: Address: City: State: Zip: Home Phone: Work

More information

2013 Application Colorado Master Gardener Volunteer

2013 Application Colorado Master Gardener Volunteer Colorado Master Gardener sm Program Colorado Gardener Certificate Training Colorado State University Extension 2013 Application Colorado Master Gardener Volunteer Full legal name: Name you go by: E-mail:

More information

Pediatric New Patient Intake Form

Pediatric New Patient Intake Form Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Email: Gender: Primary Pediatrician: Pediatrician Address:

More information

Buchanan YMCA New Traditions Elementary School

Buchanan YMCA New Traditions Elementary School Buchanan YMCA 2017-2018 New Traditions Elementary School PROGRAM! I am enrolling my child in MONTHLY care for before and/or after school.! I am enrolling my child in DROP-IN care for before and/or after

More information

Home Energy Assistance Universal Service Fund Weatherization Assistance

Home Energy Assistance Universal Service Fund Weatherization Assistance NEW JERSEY HOME ENERGY PROGRAMS Home Energy Assistance Universal Service Fund Weatherization Assistance 2010 Application Home Energy Assistance (HEA)/Universal Service Fund (USF) and Weatherization Application

More information

2018 State Funded Youth Employment Program

2018 State Funded Youth Employment Program 2018 State Funded Youth Employment Program APPLICATION OF INTEREST Completion of this application does not guarantee a slot in the program. This program is currently PENDING funding. Youth will be notified

More information

Extended Day Registration Packet

Extended Day Registration Packet St. Benedicts School Extended Day Registration Packet 2014 2015 School Year 4811 Wallingford Avenue North Seattle, Washington 98103 206-518.6009 l.wescott@stbens.net A Registration Packet Contents The

More information

YMCA PRIMETIME PARENT/GUARDIAN:

YMCA PRIMETIME PARENT/GUARDIAN: START DATE: YMCA PRIMETIME RATE: Enrollment Form 2018-2019 SITE: Does your child have food allergies? Circle YES or NO Child s Name Gender Race Age Date of Birth Home Address, City, State, Zip Home Telephone

More information

Maricopa HMIS Project PATH Intake Form

Maricopa HMIS Project PATH Intake Form 1. Information Name and/or Alias SSN ID 2. Information Type Head of Relationship to Head of 3. Entry Summary Provider Name Couple (parent & friend) & child(ren) Couple with no child(ren) Extended family

More information

ADULT APPLICATION. For Learning for Life district and council committee participants and Exploring or Explorer Club adult leaders.

ADULT APPLICATION. For Learning for Life district and council committee participants and Exploring or Explorer Club adult leaders. ADULT APPLICATION For Learning for Life district and council committee participants and Exploring or Explorer Club adult leaders. Mission: To develop and deliver engaging, research-based academic, character,

More information

YMCA Before and After School Care School Year YMCA OF PIERCE AND KITSAP COUNTIES

YMCA Before and After School Care School Year YMCA OF PIERCE AND KITSAP COUNTIES PARENT INFORMATION PAGE: Please save for All your fields reference must be completed for TACOMA registration PUBLIC packet to SCHOOLS be considered complete. YMCA Before and After School Care 2017-2018

More information

Dear Kaniksu Patient,

Dear Kaniksu Patient, Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless

More information

Directions to our office are included in this mailing.

Directions to our office are included in this mailing. Welcome to University Audiology Associates. We appreciate the opportunity to provide you with comprehensive hearing services. are services. Please complete the enclosed forms and bring these completed

More information

Sitters At Your Service, LLC

Sitters At Your Service, LLC Sitters At Your Service, LLC EMPLOYMENT APPLICATION Please mail to: P.O. Box 43021 Richmond Heights, OH 44143 216-323-7800 info@sittersays.com Sitters At Your Service, LLC is an equal opportunity/affirmative

More information

Rehabilitation Grant Program (RGP) Information & Application

Rehabilitation Grant Program (RGP) Information & Application Objective: Rehabilitation Grant Program (RGP) Information & Application Clearfield City has established the Rehabilitation Grant Program (RGP) to provide assistance for home improvements that eliminate

More information

STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16*

STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16* STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16* CONTACT INFORMATION Name: Date: Address: Home Phone: Cell Phone: Email: Over 16? Over 18? EMERGENCY CONTACT INFORMATION Emergency Contact:

More information

RHY Project Intake Form (Runaway & Homeless Youth Projects)

RHY Project Intake Form (Runaway & Homeless Youth Projects) RHY Project Intake Form (Runaway & Homeless Youth Projects) Step 1: Universal Data Collection Please complete the following basic client information and note that all fields with an * are required fields.

More information

This is an application to have your ENROLLMENT FEES WAIVED. If you need money to help with books, supplies,

This is an application to have your ENROLLMENT FEES WAIVED. If you need money to help with books, supplies, California Community Colleges 2018-19 California College Promise Grant Tuition Waiver Application This is an application to have your ENROLLMENT FEES WAIVED. If you need money to help with books, supplies,

More information

Camper Health Form Camp Y-Owasco

Camper Health Form Camp Y-Owasco Camper Health Form Camp Y-Owasco Health History Forms must be filled out by a parent/guardian. Please complete all pages. Incomplete or unsigned forms will be returned to you. Please return the completed

More information

REGISTRATION FORM. Parent Name Relationship to child. Address (if different) . Place of employment Hours - Work phone

REGISTRATION FORM. Parent Name Relationship to child. Address (if different)  . Place of employment Hours - Work phone REGISTRATION FORM FUN FITNESS CAMP All forms can be filled electronically. Please complete forms and submit with original signature and registration fee. Child s name Age Sex Address State City Zip Date

More information

Individual Volunteer Application

Individual Volunteer Application Individual Volunteer Application This application is for individuals only. Once you submit this application, the Director of Volunteer Services and Community Outreach will contact you regarding your approval

More information

2016 Child Enrolment Form

2016 Child Enrolment Form Child Outside School Hours Care 2016 Child Enrolment Form Service St Rose Outside School Hours Care 8 Rose Avenue, Collaroy Plateau NSW 2097 Phone: 0407 316 875 Email: collaroy.oshc@dbb.org.au Website:

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT 704 Mac Dade Blvd. Collingdale, Pa 19023 Phone: 215-631-3999 Email: hr@caresify.com APPLICATION FOR EMPLOYMENT Caresify is an equal opportunity employer and all applicants will be considered for employment

More information

Last Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?

Last Name First Name M.I. Name You Prefer. City State Zip  Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where? GENERAL INFORMATION Last Name First Name M.I. Name You Prefer Mailing Address How long at this address? City State Zip County If less than a year, previous address How long have you resided in the county?

More information

Lima and Ayacucho: Understanding Contemporary Peru Program Summer 2010 Acceptance Instructions

Lima and Ayacucho: Understanding Contemporary Peru Program Summer 2010 Acceptance Instructions Acceptance Instructions Congratulations on your acceptance to Boston University s summer program in Peru! This packet contains information specific to the summer program in Peru. INSTRUCTIONS In addition

More information

CODAC BEHAVIORAL HEALTH SERVICES, INC.

CODAC BEHAVIORAL HEALTH SERVICES, INC. CODAC BEHAVIORAL HEALTH SERVICES, INC. Human Resources 1650 East Ft. Lowell Rd. Suite 202 Tucson, Arizona 85719 Administration: 520 327 4505 Human Resources: 520 202 1890 Fax: 520 202 1718 Website: www.codac.org

More information

Good Afternoon Parents,

Good Afternoon Parents, Good Afternoon Parents, Thank You for looking into the Calvary Christian Mentor Program, we appreciate the opportunity to serve you and your family for the duration of summer break. Though this is a pilot

More information

BONITA UNIFIED SCHOOL DISTRICT

BONITA UNIFIED SCHOOL DISTRICT 115 West Allen Avenue San Dimas, California 91773 (909) 971-8200 Fax (909) 971-8329 Superintendent Dr. Christina Goennier Assistant Superintendents Nanette Hall Educational Services William Roberts Human

More information

North Carolina A&T State University Undergraduate Admissions Application Instructions

North Carolina A&T State University Undergraduate Admissions Application Instructions 1 North Carolina A&T State University Undergraduate Admissions Application Instructions Thank you for your interest in North Carolina A&T State University! Please complete the admissions application carefully,

More information

Cedars HOPE, Inc. RESIDENT APPLICATION

Cedars HOPE, Inc. RESIDENT APPLICATION Cedars HOPE, Inc. RESIDENT APPLICATION Agency Name: Agency address: REFERRING AGECNY INFORMATION Fax: Referring Person Name: Contact Email Date of Referral: / / Name: APPLICANT INFORMATION Date of birth:

More information

NASSAU COUNTY BOARD OF COUNTY COMMISSIONERS OFFICE OF HUMAN RESOURCES Nassau Place, Suite 5, Yulee, Florida 32097

NASSAU COUNTY BOARD OF COUNTY COMMISSIONERS OFFICE OF HUMAN RESOURCES Nassau Place, Suite 5, Yulee, Florida 32097 NASSAU COUNTY BOARD OF COUNTY COMMISSIONERS OFFICE OF HUMAN RESOURCES 96135 Nassau Place, Suite 5, Yulee, Florida 32097 P: (904) 530-6075 F: (904) 321-5797 An Equal Employment Opportunity Employer & Drug-Free

More information

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION Piedmont CASA, Inc. 818 E. High Street Charlottesville, VA 22902 Phone: 434-971-7515 Fax: 434-971-3060 VOLUNTEER APPLICATION Date: First Name: Last Name: Address: City: State: Zip: Home Phone #: Cell #:

More information

Hale Ola Kino Maika i

Hale Ola Kino Maika i We ve teamed up to make it easier for students to access healthcare in their school! Together, we are your School-Based Health Center! Waianae High School (WHS) is proud to partner with Waianae Coast Comprehensive

More information

BANGOR REGION YMCA CHILDCARE REGISTRATION FORM

BANGOR REGION YMCA CHILDCARE REGISTRATION FORM On-Site Registration Required BANGOR REGION YMCA CHILDCARE REGISTRATION FORM Childcare Information & Program Attending - Please Print ( )Early Childhood Education ( )Y-Works ( )Before School ( )After School

More information

SPRING BRANCH COMMUNITY HEALTH CENTER

SPRING BRANCH COMMUNITY HEALTH CENTER Hillendahl Clinic 1615 Hillendahl Blvd., Suite 100 Houston, TX 77055 (713) 462-6565 Pitner Clinic 8575 Pitner Road Houston, TX 77080 (713) 462-6545 Mon, Wed, Fri: 8am-5pm Tues & Thurs: 8am-8pm 1 st & 3

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

107 Commercial Street Mashpee, MA (fax)

107 Commercial Street Mashpee, MA (fax) 107 Commercial Street Mashpee, MA 02649 508-477-7090 508-477-7028 (fax) www.chcofcapecod.org Welcome to your new medical home! We are excited to offer you high quality, integrated health care services

More information

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION Orientation Date: Raiser s Edge: An Equal Employment Opportunity / Affirmative Action Employer VOLUNTEER APPLICATION Prospective volunteers will receive consideration without discrimination due to race,

More information

ZOO CREW JUNIOR DOCENT VOLUNTEER APPLICATION

ZOO CREW JUNIOR DOCENT VOLUNTEER APPLICATION ROGER WILLIAMS PARK ZOO AND RHODE ISLAND ZOOLOGICAL SOCIETY ZOO CREW JUNIOR DOCENT VOLUNTEER APPLICATION PEOPLE MAKE THE DIFFERENCE AT THE ZOO Please mail completed application to: Manager of Volunteer

More information