PDF-Organization Name ____________________________________________________

Participant Name In consideration of being allowed to participate in any way in the program related events and activities I the und. 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 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 JOHNSON BABIES CANT WAIT Organization Gender Enumeration Date Last Update Date Deactivation Reason Code Deactivation Date Reactivation Date Employer Identification Number EIN 05022014 05022014 SECTION 2 CONTACT INFORMATION Business Mailing Address TAXONOMY INFORMATION B OTHER PROVIDER IDENTIFIERS WWWHIPAASPACECOM Information provided in the current document is obtained from official source and accuracy of the information provided is the sole responsibility of the healthcare provide All change 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 BLEAKLY NICOLE TERESA MD Individual Gender Enumeration Date Last Update Date Deactivation Reason Code Deactivation Date Reactivation Date Employer Identification Number EIN Female 06122008 09112014 SECTION 2 CONTACT INFORMATION Business Mailing Add # of Golf Carts______ X $10 = __________ . The driver of the winning cart will be contacted by phone following the parade to collect their balcony tickets. The undersigned is a partic 1. W #e$" 4. L c 5. W d W (k/ (#k/ e( 7. W" ____________________________________________________ L c 9. Lhe c 10. W d) P 1. W # $" W%dt& 3. L )i"/*i"c+i" L c 5. W mzb)%r& 1. W ""e$ 4. L c 5. W W '"$e" 7. W %nek ____________________________________________________ L Lhe c 10. W P 1. W " $ " W%m#:n L ):/ #:/ L bc 5. W '''k/ " "/. is'/. 1. W !i" e 4. L c 5. W d) W 'e( 7. W#n(l ____________________________________________________ L c Lhe c 10. W b)d) P 1. W /!i" 2. W#vt % 3. L $"k/ ck/ L bc 5. W $"k"w#nt Page : 1 MOCK CAT 2010 (VERBAL SECTION) Directions for questions 1 Facts. Charter Organization owns the unit . It also owns all the resources to include any trailers, troop camping gear, and treasury!. If a Troop leaves a Chartered Organization for another, the resources must be left behind pending any negotiated transfer agreements.. access management with Single Sign-on SSO and Multi-Factor Authentication MFA universally across the operation with full visibility for auditability With Xage organizations can unify identity and acce