PDF-Participant Name

1Participant SSN or Account Mailing AddressCity State Zip CodeDate of BirthPhone NumberEmail AddressHow would you like to be contacted if additional information is required Telephone EmailE. Partner Parents Other children Doula Other present before ANDOR during labor During labor Id like Music played I will provide The lights dimmed The room as quiet as possible As few interruptions as possible As few vaginal exams as possible Hospital No SI No SI No 1 ADILABAD 1 NELLORE 1 WEST GODAVARI 2 ANANTAPUR 2 EAST GODAVARI 2 KRISHNA 3 CHITTOOR 3 SRIKAKULAM 3 VISAKHAPAATNAM 4 CUDDAPAH 4 KURNOOL 5 KARIMNAGAR 5 PRAKASAM 6 KHAMMAM 6 GUNTUR 7 MAHBUBNAGAR 8 MEDAK 9 NALGONDA 10 NIZAMABAD 11 RANGAR REPAIR FORM Company Name If Applicable First Name Last Name Address street address preferred City City State Zip Code Country Telephone Email Address Items being repaired Item Item Descripti e Master 1 Master A Utility Security Master etc You may refer to the lock report provided to your department by Lock Key Services for the correct key designation Building PLEASE DO NOT WRITE IN THIS SPACE Department Authorization Signature Departm a Candidates full Name CAPITAL LETTERS as in Matric certificate Leave a box blank between two parts of name b Fathers Name Leave a box blank between two parts of name Write Course Ser No as mentioned i D Number Please refer to Format Guidelines for the Written Entry for a more detailed explanation of these items Penalty Points Page Checked Assessed No 1 The Written Event Statement of Assurances must be signed and submitted with the entry 15 2 En HPCs - LACs S11 KERALA 01 KASARAGOD HPC LACs from Kannur) 02 KANNUR HPC (7 LACs from Kannur Distri count*&#x-0.4;䦅　):- . idbPredicate(@A,Pid,Name), . adornment(@A,Pid,Rid,Pos,Name,Sig).mg2magicPred(@A,Pid,Name,Sig):- . goalCount(@A,Pid,Name,Count), . adornment(@A,Pid, , ,Name,Sig). . California Department of . Aging. Participant Form Checklist. Participant Checklist Example. Criteria. Definition. Validation. Chose at least one . Homeless.  . Lack of a fixed, regular nighttime residence. The yellow parts should be completed before the participant gets to you. Cashiers complete the Cashier Box following all 5 steps. 5 Steps to Complete the . Cashier Box . of the . Participant Form. X. Participant Agreement This PARTICIPANT AGREEMENT is made and entered into on this day by and between below client listed hereby known as “Participant”, and Buffalo Healthy Living Magazine regarding participation in Buffalo Healthy Living and Boulevard Mall’s, “Healthy Living, Healthy You” Health Fair. ___________________________________________________________ Birthdate _________________________ (Print) Participant Questionnaire Continued Box A – I have/have had:Chest surgery, heart surgery, h YMCA of Central Florida ymcacforg 20181022YMCACampWewaHealthHistoryv100YMCA OF CENTRAL FLORIDACAMP WEWA HEALTH HISTORY FORMPlease explain any 147yes148 answers noting the number of the questions Photo PermissionParticipating in the WESO Tournament involves certain inherent risks dangers and hazards which can result in serious personal physical or bodily injury The participant and participants