MEDICAL AND HEALTH INFORMATION. L15.01 The confidentiality of health and medical information of employees is recognized by the Company and the Union.
MEDICAL AND HEALTH INFORMATION. Player Participant’s Allergies and Other Medical Conditions: Physician: Phone: ( ) Hospital/Clinic: Medical Insurance Company: Policy #: Policy Holder's Name: Agreement This Release and Waiver of Liability, Assumption of Risk, Consent, and Indemnity Agreement (the “Agreement”) must be read and signed before the undersigned, and/or player participant, attends or participates in any tournament, game, activity or other event (the “Event”) sponsored, governed or operated by the Dakota Alliance Soccer Club, Sioux Falls, South Dakota (“DASC”) in Choose an item. This Agreement is signed in consideration of the opportunity to play or participate in the Event as governed by South Dakota Law.
MEDICAL AND HEALTH INFORMATION. No, my child does not have any medical problems or known allergies Yes, my child has the following medical problems or allergies: Is the allergy/condition life threatening? If yes, does the child carry an EpiPen? Yes No ❑ ❑ ❑ ❑ Yes No Family Doctor Name: Phone number: Enrolling Parent Name: Signature: Date: / / FEES: Pre-Authorized Debit (PAD) Agreement BSC/ASC/TUESDAYS ONLY FAMILY NAME: Child’s Name: Child’s Name: Child’s Name: Child’s Name: FEE PAYMENT OPTIONS Please check all that apply: ❑ Monthly debit: Pre-authorized debit on the 8th of each month (Sept 8th 2023 – June 8th 2024) ❑ Full Payment: Payable on September 8th 2023 • EFT: Provide a blank cheque marked «VOID» or Banking Information for EFT from your bank. EFT Payee: Blessed Sacrament School, 0000 Xxxxxxx Xxxxxx, Xxxxxxxxx, XX X0X 0X0 Transaction Type: Electronic First Due Date: September 1st, 2023 Payments are recurrent, first of each month September to June. • CASH: Please make payment by the 1st of each month • CHEQUES: Cheques payable to Blessed Sacrament School PROGRAM & FEES (per student) Please check all that apply: ❑ Before School Care (BSC) - $100.00/mo ❑ After School Care (ASC) - $220.00/mo ❑ Tuesdays Only - $100.00/mo Number of children x Monthly Fee = Total Monthly Withdrawal Enrolling Parent Name: Signature: Date: / / I, as the account holder, authorized the financial institution whose name appears on the attached voided cheque, to debit my account at the identified branch under terms and conditions agreed to by me with the payee (Blessed Sacrament School) until such time as written notice to the contrary is given by me to the payee. The branch of the financial institution at which I maintain the account is not required to verify that the payment (s) is/are drawn in accordance with the authorization. A debit in paper, electronic or other form in the amount may be drawn on my account up to 10 times per calendar year. I will notify Blessed Sacrament School in writing of any changes in the account information or termination of the authorization prior to the next due date of the pre-authorized debit. I understand that no recourse will be provided through the clearing system (i.e., no automatic reimbursement in the event of a dispute). I further understand that I may seek reimbursement or recourse from Blessed Sacrament School in the event that a pre-authorized debit is erroneously charged to my account. If my bank or financial institution does not recognize a pre-authorized debit for w...
