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pg 1Are you NEW or RETURNING to Special Olympics Delaware NEW RETURNINGEmailEmailName of Employer Optional Athlete Employer OptionalCellCellSODE ATHLETEMEDICAL FORM HEALTH HISTORYPages 1. BY SIGNING YOU GIVE UP YOUR RIGHT TO RECOVER ANY COMPENSATION FOR ANY PERSONAL INJURIES DAMAGE TO YOUR PROPERTY OR FOR YOUR DEATH ARISING OUT OF YOUR USE OF VERTICAL 19256573595734715736157526657359573475734718657347573472573477657347686565734757355 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 Please fill out the Explanation of Background Screening Findings form for EACH finding reported in your background screening 2 One 1 sponsorship letter from a current employer If you are unable to obtain a sponsorship letter submit 3 character refer Student Email Address LAGIARISM AND OLLUSION Plagiarism LV5734757525D57347SUDFWLFH57347WKDW57347LQYROYHV57347WKH57347XVLQJ57347RI57347 DQRWKHU57347SHUVRQ57526V57347LQWHOOHFWXDO57347RXWSXW57347DQG57347SUHVHQWLQJ57347LW57347 DV57347RQH57526V57347RZQ575 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 Network ID tudent Loca l Address Street AptBox City State MI End Sponsor will pay for the following check all that apply Full Tuition Health Services Partial Tuition indicate percentage or amount Medical Insurance Mandatory Fees Yes if yes state amo Advantage Credit Counseling Services Inc 2403 Sidney St Suite 400 Pittsburgh PA 15203 888 511 2227 Heather Murray Alliance Credit Counseling Inc Alliance Credit Counseling Inc 15270 John J Delaney Drive Suite 575 Charlotte NC 28277 704341 1010 Mark ID Type 2 ID Type If your position is a paid or vol unteer position and you will be in contact with children elderly andor person with disabilities please read and complete the following consent Ex teacher coach foster parent nurse care giver 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 MrsMsDr First Name Middle Name Surname PNB Primary Card No Date of Birth DDMMYYYY Details of the Add on PNB Global Credit Card Applicant Full Name Mr MrsMsDr Date of Birth DDMMYYYY Name as would appear on the Add On Card Please leave space between na S citizen Yes No If you answered Yes to the question above please respond to the following two questions If your answer was No skip to the following section Are you HispanicLatino Yes No Indicate your race by choosing American Indian or Alaska Native S Department of Labor Office of Federal Contract Compliance Programs OFCCP has selected Name of Company for an equal employment opportunity EEO compliance evaluation Name of Company has been identified as having received American Recovery and Reinves No NAME OF CAPF NAME OF DWO OFFICE ADDRESS STATE DISTTPLACE CONTACT NO EMAIL ADDRESS AR Col RSYadav Garrison Commander AR Training Centre Diphu PODiphu DisttKarbi Anglong Assam Assam Haflong Karbi Anglong Last name First Name Home address City State Province Postal code Country Graduation year Gender President Vice president Secretary Treasurer Editor Member Member Member Member Member Member Member Member Member Member Key number for office use only