PARTICIPANT’S INFORMATION. Any material provided by the Participant that is marked “Confidential” may only be used by the Contractor, Payment Card Organizations, or other necessary third parties to perform services under this Participation Agreement. At any reasonable time, the Contractor or any Payment Card Organization may audit the Participant’s records relating to this Participation Agreement.
PARTICIPANT’S INFORMATION. Participant’s Name (“Participant”): (First/MI/Last): Participant’s Current Residential Address: Participant’s Phone Nos.: Mobile: Home: Participant’s Date of Birth: / / Age: Gender: Male Female Emergency Contact Name: Emergency Contact Mobile No.: SECTION 2: PARTICIPANT’S PARENT/LEGAL GUARDIAN INFORMATION Name of Parent/Legal Guardian: (First/MI/Last) Current Residential Address (if different than Participant’s): Phone Nos.: Mobile: Home: Work: Name of Parent/Legal Guardian 2: (First/MI/Last) Current Residential Address (if different than Participant’s): Phone Nos.: Mobile: Home: Work: Only the following person is authorized to pick up my child at the conclusion of the Event (Person to have valid ID for verification):
PARTICIPANT’S INFORMATION. It is essential that the Indian partners inform at the proposal preparation stage itself that they will not sign the EU Grant Agreement (GA). They should indicate, however, that they participate as an 'Associated Partner'. At the time of online submission of Horizon Europe proposal, the name of the Indian participant(s) should be included as associated partner(s).
PARTICIPANT’S INFORMATION. Name of Participant Receiving PDS: (Print/type) Address: (Number) (Street) (Unit/Apt.) (City) (State) (Zip Code) Home Phone Number: / / Cell Phone Number: / / E-mail Address: PARTICIPANT’S EMERGENCY CONTACT INFORMATION: Name of Emergency Contact: (Print/type) Address: (Number) (Street) (Unit/Apt.) (City) (State) (Zip Code) Home Phone Number: / / Cell Phone Number: / / E-mail Address: COMMON LAW EMPLOYER: (CHECK ONE BOX) □ Participant □ Designated Common Law Employer If the Participant designates an alternative common law employer, complete the information on the next page. Designated Common Law Employer Information (if applicable): Name: (Print/type) Address: (Number) (Street) (Unit/Apt.) (City) (State) (Zip Code) Home Phone Number: / / Cell Phone Number: / / E-mail Address: The Participant or Designated CLE, when appointed by the Participant, must met the following criteria in order to be the CLE: Common Law Employer (CLE) Requirements and Responsibilities:
PARTICIPANT’S INFORMATION. For any Participant that will receive the Program Service, Group may provide CVS, at least 24 hours ahead of the scheduled visit(s), with completed vaccine administration records and consent forms, which will contain, but not necessarily be limited to, the Participant’s full name, date of birth, and Co-payment, if applicable. Notwithstanding the foregoing, any applicable Co-payments or self-pay amounts will be collected by Group from the Participant at Group’s facility at the time that Program Services are provided.
PARTICIPANT’S INFORMATION. Complete this part. Print the name of the adult participant enrolled in the center.
PARTICIPANT’S INFORMATION. Manager (IM); and
PARTICIPANT’S INFORMATION. Participant’s Name: _________________________________ Phone Number: _________________________________ Email: _________________________________ Emergency Contact Emergency Contact’s Full Name (Required): _________________________________ Emergency Contact’s Phone Number (Required): _________________________________ By signing below, I am confirming that I have carefully read and understood the contents of the foregoing language, have provided accurate personal information, have been given a copy of the terms, and I specifically intend it to cover my participation at the Snow College off-road vehicle activity. I also understand that an electronic signature has the same legal effect and can be enforced the same way as a written signature. Today’s Date: _________________________________ Signature: _________________________________
