PRESCHOOL REGISTRATION AND FINANCIAL AGREEMENT 2019-20Registration and Financial Agreement • March 28th, 2019
Child’s Name: Birth date: Parent or Guardian: Contact phone # Parent or Guardian: Contact phone # Local Church Affiliation: Parent/Guardian Email Address:
DEPENDENT REGISTRATION AND FINANCIAL AGREEMENT FOR ACCESS TO WILCE PHARMACYRegistration and Financial Agreement • October 17th, 2011
Ohio State Students: Use this form to register your dependent(s) to have their prescriptions filled at the Student Health Services Pharmacy located within the Wilce Student Health Center. Co-pay or co-insurance amounts are due at the time of service. If you are not covered by a participating prescription plan or have not paid your Student Health Insurance premium in full, then payment in full is required prior to receipt of the medication.
Registration and Financial Agreement between Smart Stars Academy and .Registration and Financial Agreement • August 22nd, 2013
$ per month, which is due on the first of each month (a late payment charge of $50 will be added for payments made after 5th of each month.)
Smart Stars Academy IIRegistration and Financial Agreement • May 22nd, 2020
$ per month, which is due on the first of each month (a late payment charge of $50 will be added for payments made after 5th of each month.)
Dance Action Registration and Financial AgreementRegistration and Financial Agreement • July 27th, 2021
Suspension: The Director of the studio reserves the right to suspend or terminate any student for failure to comply with the Policies and regulations. This may include but not be limited to failure to pay tuition, or behavior that is (in the opinion of the Director) to be prejudicial to the welfare, good order and character of the studio.
Client Registration and Financial AgreementRegistration and Financial Agreement • December 26th, 2017
With the exception of emergencies, a minimum of 24 hours’ notice is required for cancellation of appointments to avoid being responsible for a MISSED appointment fee of $50.00.
Client Registration and Financial AgreementRegistration and Financial Agreement • December 26th, 2019
With the exception of emergencies, a minimum of 24 hours’ notice is required for cancellation of appointments to avoid being responsible for a MISSED appointment fee of $50.00.
REGISTRATION AND FINANCIAL AGREEMENT – PINNACLE HEALTHCARE – PINNACLE MEDICAL GROUPRegistration and Financial Agreement • February 9th, 2021
It is understood that this authorization for medical treatment and/or testing is given in advance for any specific diagnosis, treatment of emergency care or testing that may be required by the physician in the exercise of their best medical judgment. I understand that it is my responsibility to know the specific benefits of my insurance coverage. Insurance coverage is an agreement between myself and my insurance company. Therefore, it is my responsibility to make payment for non-covered services, including co-payments or co-insurance and deductibles. I hereby authorize the release of any pertinent medical information or records to the insurance carrier, ifdeemed necessary to process my medical claim. I hereby acknowledge that I have received a copy of Pinnacle HealthCare’s notice of Privacy Practices. I further acknowledge that a copy of the current Privacy Practice notice is posted in the reception area, and that I will be offered a copy of any amended notice of Privacy Practice at
Smart Stars Academy IIRegistration and Financial Agreement • May 22nd, 2020
$ per month, which is due on the first of each month (a late payment charge of $50 will be added for payments made after 5th of each month.)
