PLEASE READ THIS DOCUMENT CAREFULLY. This is a legally binding agreement (the “Registration Agreement”) between you (“you” or “your”) and Health Current (“we” or “us”) about your submission of documents to the AzHDR. If the instructions herein are not followed, your form(s) may be rejected. How to complete this Agreement: • Read the agreement and complete this form. • Fill in all blank spaces on this form. • Sign and date form. • Attach a copy of the witnessed or notarized advance directive(s). DO NOT SEND ORIGINALS TO THE AZHDR. • Mail to: AzHDR – Health Current 0000 X. 0xx Xx., Xxx. 000 Xxxxxxx, XX 00000 • Or fax to: 000-000-0000 • Or email to: xxxxxxxxx@xxxxx.xxx Processing time: up to three weeks. Check the applicable box (check only one box per submission): New registration. Replace an advance directive(s) presently in the AzHDR with the new one(s) attached. Replace all documents presently in the registry with the new one(s) attached. Replace only the following document type(s) presently in the registry with the new one(s) attached while leaving the others in place (check all that apply): Living will Health care power of attorney Mental health care power of attorney DNR Add an additional document to my currently stored directive(s). Inactivate my account: Check this box if you do not want your documents to be active in the registry. Change registrant demographic information previously submitted (update your information on this form). Health Current | 0000 X. 0xx Xx., Xxx. 000 | Xxxxxxx, XX 00000 P: 000-000-0000 | F: 000-000-0000 | xxxxx@xxxxxxxxxxxxx.xxx | xxxxx.xxx
PLEASE READ THIS DOCUMENT CAREFULLY. I acknowledge that the Company will use this Agreement to govern my actions and responsibilities during my participation in the Puzzle Adventure Room (the “Activity”).
PLEASE READ THIS DOCUMENT CAREFULLY. University agrees to provide Student space in University-Operated Residence Halls. The term of this Agreement shall be for one academic year, including both the Fall and Spring semesters, and Summer semester, if applicable (the “Term”), unless this Agreement is cancelled in accordance with the section of this Agreement entitled “Termination.” Residing in University-Operated Residence Halls is considered a fundamental part of the Student’s education, therefore this Agreement is only a license to occupy and use the residential space assigned to the Student for limited purposes (the “Residential Space”) and is not a lease of the University’s property. This Agreement is personal and non-transferable, and it is not a commitment of admission to the University. The University reserves the right, at its sole discretion, to determine if any past behavior, conduct, or activity of any individual is such that the interest(s) of the University, the Student, and/or other students would best be served by terminating this Agreement. In addition, the Student acknowledges that convicted and/or registered sexual offenders are not allowed to reside in University-Operated Residence Halls. The Student must pay to the University a one hundred and thirty-five dollar ($135) Application Fee. The Student represents to the University that the Student is eighteen (18) years of age or older at the time this Agreement is executed and the University relies on that representation. If the Student is under the age of eighteen (18) years, then one of the Student’s parents or legal guardians must sign this Agreement and that person is hereby made a party to this Agreement, subject to all terms and conditions of this Agreement. The University’s “Residence Halls Service Agreement Terms and Conditions” shall be considered part of this Agreement although it may not be attached physically hereto. The Student’s occupancy is also governed by the “Living on Campus Housing Guide” and “Winston-Salem State University’s Student Handbook”, as currently written or as may be amended in the future.
