5600pmbmp0385 instructions rev. 11/2014 commonwealth of pennsylvania department of environmental protection bureau of mining programs instructions for completing renewal application coal mining activity permit general information 1. this...
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Spectrum psychological associates, inc. consent to treat i, (print the patient s full name on the line) authorize providers of the spectrum psychological associates, inc. (spectrum) to treat me for my health, wellness and routine care management....
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Temporary child guardian consent form the parent(s)/ guardian(s) full name(s) and surname(s): and address: contact phone number(s) and details: the child(ren) full name(s) and date of birth: the temporary guardian(s) full name(s) and surname(s):...
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Dental hygiene observations dental health care practitioners: we ask that prospective dental hygiene applicants observe the following dental hygiene related procedures to promote understanding of dental and dental hygiene practices. through...
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Material safety data sheet section 1 product and company identification cat elc (extended life coolant) extender product use: antifreeze/coolant product number(s): 1195151, 1195152, 16279, 1993972, 2100786, 2154241, 2193039, cps236279 company...
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Medical treatment authorization letter page 1 of 1 medical treatment authorization letter guardian s name guardian s address guardian s home & contact info date: to whom it may concern: our minor child(ren) , will be traveling with and under the...
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Patient name: kaiser # date of birth: kaiser foundation hospitals permanente medical groups address: city: authorization for use or disclosure state: zip code: of patient health information ( ) telephone number: note: fees may apply to certain...
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Ridgefield physical therapy consent form to treat minors date: patient name: date of birth: i, , parent or legal guardian of , hereby: ? grant authorization for the above minor to be seen, without my presence at this visit and throughout the...
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Integrative womens healthcare of nevada robi burns, m.d. consent for medical treatment of a minor i am the parent(s) of the minor child (child name). i temporarily entrust (child name) to the care of robi burns, m.d./integrative womens healthcare...
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Children of the dump notarized consent to medical treatment each unaccompanied minor needs to have a notarized consent to medical treatment form with the signature of his/her custodial parent or legal guardian. date: i/we , hereby grant parent...
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Guardian s authorization of minor student to execute program deviation waiver my n.u.in participant, , will be under the age of 18 for all or a portion of the n.u.in program. by signing this authorization, i hereby grant to my child the authority...
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Where: the robinson center: 1301 sunnyside drive, university of kansas west entrance. who: area youth entering 3rd to please drop off, fax, or mail the completed application to: big brothers big sisters address: city: state: zip: dob:
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Page 1 of 6 december 28, 2011 ed. 4.0 city of jersey city general development application this section to be completed by city staff only intake date: date validated as an application for development: date deemed complete: application no. 1....
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Child labor law guide to child employment by performing arts organizations this is an abridged version of the michigan law and performing arts guidelines. the official copy of performing arts authorization form is included and must be submitted,...
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Attachment consent for release of information patient s name dob: address i, the undersigned, hereby request and give permission to: (name of person or agency releasing information) for the release of medical information from the treatment period...
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