Acknowledgement of Receipt of Copy. I acknowledge receiving g a copy of this Agreement and understand the terms and conditions under which the person who I have selected as a Private Service Provider may provide services to my child at a Xxxxx County Public School. Parent/Guardian/Educational Surrogate Requesting Services Signed Print Name
Acknowledgement of Receipt of Copy. MORTGAGOR HEREBY DECLARES AND ACKNOWLEDGES THAT IT HAS RECEIVED, WITHOUT CHARGE, A TRUE COPY OF THIS MORTGAGE.
Acknowledgement of Receipt of Copy. By execution of this Agreement, the Optionee acknowledges having received a copy of the Plan. The Optionee and the Company have executed this Agreement as of the ____ day of ________, 20__. OPTIONEE DAKOTA PLAINS HOLDINGS, INC. By Its
Acknowledgement of Receipt of Copy. 15. The Operator acknowledges receipt of a true copy of this agreement.
Acknowledgement of Receipt of Copy. I acknowledge receiving a copy of this Agreement and understand the terms and conditions under which the person who I have selected as a Private Instructional Provider may provide services to my child at an Osceola County Public School. Parent/Guardian/Educational Surrogate Requesting Services Parent / Guardian Signature Print Parent / Guardian Name Date: EXHIBIT A The School District of Osceola County, Florida PARENTAL CONSENT FORM – PRIVATE INSTRUCTIONAL PERSONNEL To be completed by the Parent/Guardian/Educational Surrogate Student Last Name First M. School Student ID # Grade DOB Check Type of Therapy: ☐ BACB BCaBA ☐ XXX ☐ OT ☐ PT ☐ SLP ☐ Psychologist ☐ Clinical Social Worker _ First and Last name of Private Provider Private Provider Address City State Zip Private Provider Phone # Private Provider E-mail Agency Issuing Certificate (License) Certificate (License) # (XXX #) Certificate (License) Expiration Date Self Employed ☐ Yes ☐ No Employing Agency: (**RBTs must indicate employing agency**) Agency Medicaid #: Supervising Behavior Analyst Certification # Name of Supervising Behavior Analyst – Agency Address City State Zip Supervising above listed XXX/ BCaBA Supervising Behavior Analyst Phone # Supervising Behavior Analyst e-mail Summary of Services to be provided: Consent and Hold Harmless I, , consent to the above-named service provider to provide services to my child, at during the current school year. I/We, the undersigned Parent(s), agree to defend, fully indemnify, and hold harmless The School District of Osceola County, Florida, and its employees for any expense, cost, loss, damage, claim, judgment or claims bill incurred or rendered against the School District of Osceola County, Florida, including attorney’s fees and investigation expenses (pre-suit, suit, trial appeal, and post appeal proceedings) on account of any intentional or negligent acts or omissions of the Private Instructional Personnel hired by me/us, or negligent actions or omissions of its employees, agents, or servants arising out of the use of any facility, or the provision of any services to my child and for any violation of the rights of my child by the Private Instructional Personnel hired by me/us. This provision shall survive the termination of any Agreement between the School Board and the Private Instructional Personnel and shall remain in full force and effect until the expiration of any statute of limitations. Parent/Guardian/Educational Surrogate Signature Parent/Guardian...
