PLEASE ANSWER THE FOLLOWING QUESTIONS. During the previous twelve (12) months, have you entered into contracts, including the present contract, bid or proposal, with the City of Berkeley for a cumulative amount of $100,000.00 or more? If no, this Contract is NOT subject to the requirements of the LWO, and you may continue to Section II. If yes, please continue to question 2(b).
PLEASE ANSWER THE FOLLOWING QUESTIONS. Does your child take any Foreign language courses in Grades 6, 7 or 8? If yes, please check off one or more of the following two language selections. Does your child take band or chorus in Grades 6‐8? Yes French Yes No Spanish No If yes, please check off one or both of the following two course selection. Does your child participate in athletics? (for Grades 6‐12) Band Yes Chorus No NEWARK CENTRAL SCHOOL DISTRICT ATHLETIC DEPARTMENT FORM FOR GRADES 7‐12 FAX # 332‐3234 Previous School Attended: Student’s address while attending the above school Street and Number City, State, Zip With whom did student reside at this address? Father Mother Guardian 000 XXXX XXXXXX X NEWARK, NEW YORK (000) 000-0000 FAX (31 TREET 14513 5) 332-3517 SIGNATURE OF PARENT/GUARDIAN: ** These records should include ** ** PLEASE SIGN ** *Please provide numerical equivalent if alphabetical grades are reported* Newark Middle School – Grades 6 – 8 Attn: Xxxxx Xxxx, Building Secretary Xxxxxxx School – Grades K‐2 Attn: Xxxxxxx Xxxxxx, Building Secretary Lincoln School – Grades K‐2 Attn: Xxxxx Xxxxxxxxx, Building Secretary Newark Central School District Student Registration Form FOR OFFICE USE ONLY Student #: Grade: EC: Teacher: SIBLINGS / RELATIONSHIPS IN THE HOME BIRTH DATE GRADE SCHOOL ATTENDING **(PLEASE PRINT, EXCEPT WHERE SIGNATURE IS REQUIRED)** FIRST NAME M.I GENDER I F CHILD IS NOT SCHOOL AGE, LAST NAME FIRST NAME M.I RELATIONSHIP TO STUDENT Student’s Name Newark Central School District Registration Form, Page 2 Newark Central School district assumes that all custodial parents and legal guardians listed below are allowed to pick this student up from school unless parent provides school with a current, legal, valid court order indicating otherwise. PARENT/GUARDIAN INFORMATION Student’s Name Newark Central School District Registration Form, Page 3 EMERGENCY CONTACTS (Beyond Parent/Guardian) DAYCARE PROVIDER In the case of when parents are living in separate households, both parents may want to be included in any mailings the school may send with information in regards to their child. Please indicate in the spaces below those parents who are to be included in mailings. If there are any legal restrictions (Ex.: Order of Protection, Sole Physical Custody with supervised visitation) please indicate in the Custodial Information section of this registration on Page 1.
PLEASE ANSWER THE FOLLOWING QUESTIONS. Have you ever been asked to give a right-of-way easement to EJ Water?
PLEASE ANSWER THE FOLLOWING QUESTIONS. Have you ever engaged in sexual misconduct, such as sexual abuse, in any confinement setting such as jails, prisons, and/or juvenile detention facilities? YES ❑ NO ❑X
PLEASE ANSWER THE FOLLOWING QUESTIONS. If yes to any of the following questions, please attach a detailed information sheet If yes to any of the following questions, please attach a detailed information sheet. Please include name of court in which suit was filed, caption and docket number of case, name and address of attorney defending you, and any other relevant details. If yes to any of the following questions, please include a sheet of detailed information. CLINICAL PRIVILEGES PROFICIENT REQUESTED GENERAL ANESTHESIA: REGIONAL ANESTHESIA: DIAGNOSTIC/THERAPEUTIC BLOCKS: PROCEDURES: IV ADMINISTRATION OF:
PLEASE ANSWER THE FOLLOWING QUESTIONS. Does your child take any Foreign language courses in Grades 6, 7 or 8? If yes, please check off one or more of the following two language selections. Does your child take band or chorus in Grades 6-8? Yes French Yes No Spanish No If yes, please check off one or both of the following two course selection. Does your child participate in athletics? (for Grades 6-12) Band Yes Chorus No NEWARK CENTRAL SCHOOL DISTRICT ATHLETIC DEPARTMENT FORM FOR GRADES 7-12 Previous School Attended: Student’s address while attending the above school Street and Number City, State, Zip With whom did student reside at this address? Father Mother Guardian Superintendent of Schools (000) 000-0000 FAX (000) 000-0000 XXXXXX X. XXXXX XXXXXX X. XXXX XXXXXXXX XXXXXX ** These records should include ** *Please provide numerical equivalent if alphabetical grades are reported*
PLEASE ANSWER THE FOLLOWING QUESTIONS. Your answers will be held in the strictest of confidence. (Circle one) Yes No 1. Do you currently use illegal drugs? Yes No 2. Have you ever been convicted of the illegal manufacture, sale or Possesion of drugs? Yes No 3. Have you ever been convicted of a criminal offense? (Conviction of a crime is not an automatic bar to employment. Lords of Soccer will consider the nature of the offense, the date, and the relationship between the offense and the position applied for.) Yes No 4. Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? Yes No 5. Are you subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection? I understand that the Lords of Soccer camps may deny employment to any person who answers any of the above questions, numbered 1-5,
PLEASE ANSWER THE FOLLOWING QUESTIONS. Do you have a Doing Business As (DBA) account? If so, please provide the Legal and DBA names. Legal Name DBA
PLEASE ANSWER THE FOLLOWING QUESTIONS. Are you under indictment or information (an information is a formal accusation of a crime made by a prosecuting attorney) in any court for a crime for which a judge could imprison you for more than one (1) year? YES □ NO □
PLEASE ANSWER THE FOLLOWING QUESTIONS. Skipper: Address:
