Date of Birth means the subject’s date of birth using MMDDCCYY format as indicated in Exhibit A.
Date of Birth. Age: Grade: Emergency contact: Date(s) of safety instruction: Number of credit hours to be granted: Concurrent, related academic course*: *For a student in a state-approved CTE program, the above verification must be made by a vocationally-certificated teacher or coordinator. Type of Placement (check one): Non-CTE Work-Based CTE Work-Based Learning (Program Serial Number __________________) Paid or Unpaid Work-Based Paid or Capstone In-District (gr. 11&12 only) Special Education Work-Based Unpaid Less-Than-Class-Size Name of Firm: Supervisor: Address: Phone: City: Zip: Worker’s Disability Carrier: Policy No. Liability Insurance Carrier: Policy No. Job Title: Date Employment Begins: Ends: Hours to be worked: Mon Tue Wed Thu Fri Sat Sun Earliest Latest Avg. Hrs. Per Day*: Xxx Xxx. Per Week**: Starting Wage: *Cannot compute to more than ½ of the pupil’s FTE. **Work and school hours cannot exceed 48 hours per week for students under age 18 IMPORTANT: IN-DISTRICT placements MUST be directly related to one of the following: State-Approved CTE work-based (Name of related CTE Program: ) PSN from above: Postsecondary career and employment goals and objectives in the pupil’s transition service plan developed for special education services. Position/Assignment: Supervisor: Beginning Date: Ending Date: This assignment is: (check one) for the marking period for the semester for the school year Hours to be worked (must occur during scheduled classroom time): Mon Tue Wed Thu Fri Education/Career Goal(s): List the education goals related to this placement that align with the student’s career pathway contained in the student’s educational development plan. For unpaid work-based experiences, specific, unduplicated skills must be listed for each 45 hours of placement. ___________________________________________________________________________________________________________________ *Attach copy of the EDP or IEP.
Date of Birth means the month, day, and year on which the patient whose hospitalization is being recorded was born.
Examples of Date of Birth in a sentence
Proposed Position: Name of Firm: Name of Staff: Profession: Date of Birth: Years with Firm: Nationality: Membership in Professional Societies: Detailed Tasks Assigned: Key Qualifications: [Give an outline of staff member’s experience and training most pertinent to tasks on assignment.
Please give us your detailsMr Ms Miss Mrs OtherSurname Given Name/s Date of Birth Driver’s licence number Driver’s licence expiry date Driver’s licence state Passport no.
Name: % Share: Address: Relationship: Date of Birth: Social Security #: Trust Name and Date (if beneficiary is a trust): Trustee of Trust: 2.
Support StaffTPF – 5: Format of Curriculum Vitae (CV) for Proposed Professional Staff Proposed Position: Name of Firm: Name of Staff: Profession: Date of Birth: Years with Firm/Entity: Nationality: Membership in Professional Societies: Detailed Tasks Assigned: Key Qualifications:[Give an outline of staff member’s experience and training most pertinent to tasks on assignment.
Student Name District Student ID_ Date of Birth SSID Parent/Guardian Signature Date District or Charter School Please provide a copy of the Home Language Survey to the EL Coordinator/Main Contact on site.
More Definitions of Date of Birth
Date of Birth. SSN: Date: Updated: Initials/Date Initials/Date Initials/Date By signing below, I am acknowledging that I am aware of the HIPAA Privacy Act. I also acknowledge that I have been offered a copy of the Mid-Atlantic Women’s Care Privacy Notice pursuant to the Federal regulations known as the HIPAA Privacy Rule. If I am unaware of this, a copy shall be provided to me. Patient Signature Patient PRINTED Name Date Patient Name: Date: _
Date of Birth. SPA Type: Guaranteed Performance-Based This Standard Player Agreement (this “SPA”) is made as of the Effective Date by and between the Player and the Club (each a “Party” and, collectively, the “Parties”). In consideration for the mutual promises contained herein, the Parties agree as follows:
Date of Birth. Month: Day: Year: __ Home Phone: Cell Phone: Work Phone:__ ________ Organization/Group/Club (if applicable) _ _
Date of Birth. Age: Sex:
Date of Birth. Age: Gender: M F Child’s T-shirt Size: Youth: S M L XL Adult: S M ● A $50.00 deposit is required per child per camp. Deposits are not refundable or transferable. ● Day Camp: Each camp will be held with a $50.00 non-refundable deposit for each camper per weekly session, at time of registration to hold the spot. Deposits are applied toward the cost of each session. ● Cancellations/Refunds/Credits: Refunds or credits for camp are available only with a doctor’s note explaining injury or inability to attend YMCA camp due to illness, accident or injury. The $50.00 deposit for each child per camp, will not be refunded or credited. There is a $25.00 fee due for all NSF checks and that payment must be made within 24 hours in order for your child to attend camp. ● Each camp will be drafted from your checking or savings or credit card, please see the Summer Camp Billing form to see camp draft dates. ● All camps must be paid in full the Wednesday prior to the start of camp. If payment is not received in full after the above date, you will be charged a $15.00 late fee. ● Cancellations/Refunds/Credits: Refunds or credits for a camp are available two weeks prior to the first week of camp only! However, the deposit of $50.00 per week for the day camps is a NON-REFUNDABLE deposit and non-transferable. ● If you wish to change camp weeks, you will be asked to pay a deposit for the camp you are changing into. There will be no option to switch or transfer camps after the Wednesday of the week prior to camp, in order to maintain staff/camper ratios needed for safety. ● All campers must hold a valid YMCA membership to receive the member rate and must remain valid until Sept. 1, 2019. If you register as a non-member we will not change the camp registration rate if you later become a member. ● Families that have applied for Action for Children and/or approved by Action for Children need to pay the estimated co-pay to be accepted into the program. Action for Children coverage does not hold your child’s spot. Families that have applied for Action for Children are responsible for all camp payments until they are approved. ● Action for children does not cover all costs of camp-the remaining balance is the parent’s responsibility. I have read and understand the above statements. I fully understand my responsibility for payment of summer camp for any registered child in my care. I also understand my child may be released from the camp program if I have not met these financial obligation...
Date of Birth. Email: Participant’s Signature (only if age 18 or over):
Date of Birth. Age: Sex: □ Non- Binary □ Male □ Female Does the patient live or work in a congregate setting (e.g., long-term care facility, shelter, group home, prison) □ YES □ NO Date of symptom onset: Symptoms Observed: □ None Does the patient have any underlying conditions? □ Fever □ None □ Immunocompromised □ Tiredness □ Runny nose □ Unknown □ Pregnant □ Dry Cough □ Loss of smell □ Diabetes □ Chronic Lung Disease □ Body Ache □ Diarrhea □ Hypertension □ Chronic Liver Disease □ Nasal Congestion □ Loss of Appetite □ Cardiac Disease □ Chronic Kidney Disease LABORATORY TESTING – Completed by Patient □ Other Has the patient received the COVID-19 Vaccine? □ Yes □ No Which COVID-19 Vaccine has the patient received? □ Moderna □ Pfizer □ Xxxxxxx & Xxxxxxx vaccine GROUP: ID: □ CASH ONLY – BILL TO CLIENT N/A