PERSONAL HISTORY. The Employee represents and warrants to the Employer that there is no scandal, whether or not involving a criminal conviction, in his/her past which if made public during his/her employment with the Employer would tend to harm the reputation of the Employer, whether among the public at large or among the clergy, employees or volunteer staff of the Employee.
PERSONAL HISTORY. In order to understand our clients’ background, and to assist in establishing the most suitable structure and banking arrangements (if required), information regarding our clients’ work experience and qualifications is likely to be of considerable assistance, together with a clear understanding of our clients’ wealth financial circumstances both past and present.
PERSONAL HISTORY. A. Does Participant have allergies to any medicines, foods, bites and stings, etc? O yes O no If “yes”, please list:
B. Will Participant take any prescription and/or non-prescription medications during our program? O yes O no Medication & Dosage Side Effects/Restrictions For what condition?
C. We require a tetanus immunization within 10 years of the program. When was Particpant’s last tetanus inoculation? / /
D. Are there any other health issues or restrictions that our program staff needs to be made aware of for your safety during your participation with the NWMC programs? If “yes”, please explain:
PERSONAL HISTORY. A. Does participant have allergies to any medicines, foods, bites and/or stings, etc? Any dietary restrictions? O yes O no If “yes”, please list and describe need, reactions, etc:
B. Will you take any prescription and/or non-prescription medications during our program? O yes O no Med. & Dosage Side Effects/Restrictions For what condition?
C. The NWMC, WBF, & SSE requires a tetanus immunization within 10 years of the program. When was your last tetanus inoculation? / /
D. Are there any other health issues or restrictions that our program staff needs to be made aware of for your safety during your participation with NWMC, WBF, & SSE programs?
PERSONAL HISTORY. As a member of the community at Summit Pacific College and potentially a credential holder of the Pentecostal Assemblies of Canada (PAOC), students need to be willing to comply with lifestyle commitments belonging to the community, which involve abstention from alcohol, tobacco, non-medical drugs, occultic activity and separation from all suggestion of immoral or unethical behavior. As Summit Pacific College is the educational arm of the PAOC we affirm lifestyle values that are consistent with credentialing responsibilities.
PERSONAL HISTORY. Do you ever have any injuries, difficulties or problems during a high intensity exercise? If so, please Specify _ _.
PERSONAL HISTORY. Do you have any conditions, medical or otherwise, that may prevent you from performing your duties as a volunteer for Visiting Neighbors, Inc.? Yes No Do you have any physical limitations or concerns? Yes No Are you presently taking any medications/substances, prescribed or otherwise, that may prevent you from your performance as a volunteer for Visiting Neighbors, Inc.? Yes No Do you have any adverse history regarding financial integrity? Yes No Do you have a drinking or drug problem that would interfere with your ability to perform the service for which you have applied? Yes No Do you have a history of mental or emotional instability for which you have not obtained treatment? Yes No Do you have a history of general behavioral or conduct issues? Yes No Other matters which are important to your performance as a volunteer (list below) Yes No If you answered yes to any of the questions above, please explain:
PERSONAL HISTORY. Do you wear contact lenses? yes no (Please remove contacts prior to Eye Liner procedure.) Have you ever taken or do you now take Accutane? (This is an acne medicine) Yes No IF YES, last dose of Accutane taken: Month Day Year Please list your routine medications here (include herbs and vitamins):
PERSONAL HISTORY. Does child walk well? Yes No Run? Yes No Is your child a good climber? Does your child fall easily? Talking? Yes No In phrases? Yes_ _No In sentences? Yes No Does your child speak any other language? If yes, which Physical Disabilities? Yes No Serious Illnesses? Yes No Known Allergies? Yes No Other Conditions or Limitations Is your child toilet trained? Yes No In the process of being trained? Yes No If yes, are you using a potty chair ? Toilet seat ? Does your child have frequent toilet accidents? Yes No How does your child react to accidents? Does your child let you know when he/she needs to use the toilet? Defecate word Vomit word Urinate word
PERSONAL HISTORY. Have you had any major injuries or accidents? ❑ No ❑ Yes If yes, please list with dates: Have you had any major illness, surgery or hospitalizations? ❑ No ❑ Yes If yes, please list with dates: Are you pregnant or could you be pregnant? ❑ No ❑ Yes If yes, how many months? Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past. Number of bowel movements daily? Are they? ❑ Loose ❑ Normal ❑ Hard ❑ Incomplete Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past.
