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Enrollment forms packet Hawaii Technology Academy 94-810 Moloalo Street 2nd Floor Waipahu HI 96797 Enrollment Forms Packet EFP Ph. 1. 808. 676. 5444 www. k12. com/hta Please review the information below. Based on your student s grade and applicable circumstances you are required to submit documentation in order to complete this step in the enrollment process. You can fax or mail the required paperwork. Important Note Please send copies do not mail the original documents Fax preferred Mail 1-808-676-5470 Required For Provided by Official Birth Certificate not the hospital issued certificate Proof of Residency Copy of rental/mortgage document OR Current utility bill OR Notice of base housing assignment or Notarized statement of residence if living with relative. Report Card The most recent Report Card except for students enrolling in Kindergarten or always homeschooled* Immunization Record and Results of a Tuberculosis examination Current Immunization Record. Tuberculosis TB clearance must be completed within one year before first entrance into school in Hawaii and must be performed by the State of Hawaii Department of Health or by a U*S* licensed physician advanced practice registered nurse APRN or physician assistant PA. Please fill out and return the Request for Immunization Exemption on Religious Grounds form included in the Enrollment Forms Packet if applicable. Student s Health Record A physical examination must be completed within one year before first attending school in Hawaii and must be performed by a U*S* licensed physician APRN or PA. Provided in this packet Release of Records This form is required to transfer your student s previous school records. If your student is entering Kindergarten or was not previously enrolled in a school write Not Applicable on the form* THIS IS NOT A WITHDRAWAL FORM. Contact your student s school to follow proper withdrawal procedures. Network and Internet User Agreement for students under the age of 18. Home Language Survey Please make sure that you answer all sections of this form* Self Administration of Medication Please have your physician complete and sign if applicable. If not applicable please write N/A and sign form* McKinney-Vento Eligibility Questionnaire Required for all 10 -11th Grade Students Description Proof of Age Item Unofficial Transcripts You will need to request an unofficial transcript from your student s current school which will show your student s academic standing. This is required in order to place all 10th and 11th graders enrolling in second semester. Once your student is approved we will receive the official transcript. IEP student with an IEP or other Special Evaluation Report Education needs Required for students that have a 504 plan 504 Accommodation Plan A copy of your student s current IEP Individualized Education Plan. Because the IEP expires yearly please submit the current IEP. The Evaluation Report is valid for 3 years. If you do not have a copy of your student s ER you can request a copy from your student s current school* expires yearly please submit the current 504.

Occupational health enrollment... OCCUPATIONAL HEALTH ENROLLMENT FORM. COVER SHEET. IMPORTANT NOTICE: This form is to be submitted directly to the University of Texas...

Trs enrollment form TRS ENROLLMENT APPLICATION FOR PARAPROFESSIONALS INSTRUCTIONS PLEASE READ CAREFULLY his application will enable you to enroll as a member of TRS as of the date TRS receives your enrollment T application. Before completing this application please read the attached Enrolling in TRS brochure for more details about joining TRS including membership eligibility membership date pension contributions required documentation and membership in other retire...

Amerivantage select hmo indivi... Amerivantage Select (HMO) Individual Disenrollment Form 2017 Mail the completed form to the address below: Amerigroup P.O. Box 659403 San Antonio, TX 782659714 Or fax the completed form to: 18008338554

Enrollment forms are in pdf fo... Enrollment Packet Instructions PLEASE READ THESE DIRECTIONS BEFORE COMPLETING ENROLLMENT FORMS Enrollment forms are in PDF format and require Adobe Reader. If you do not have Adobe Reader, it can

Special risk accident amp liab... Special Risk Accident & Liability Insurance Enrollment Form Texas Tech University System Camp and Conference Part l Named Insured: Texas Tech University System Camps and Conferences 1. Name of

Gsrp enrollment forms detroit... Aug 10, 2011 ... Permission forms for swim, photo, and health forms (for one or two children). ... providers are screened by both Forest Hills Public Schools and the State of Michigan. ..... with

Moda health enrollment form Enrollment application change of information form Moda Health use only Group number Subscriber number Medical 2-99 To expedite your application please print legibly in black or blue ink and return as instructed. Please complete all sections of this application. If the application is incomplete or additional information is required your effective date may be delayed. Section 1 Application type You ll need a special enrollment reason for some changes made outside the open enrollment period. Special enrollment includes adding dependents to an existing plan and enrolling in the plan due to loss of other coverage. The reason I am applying or making a change is Open enrollment Date of event / Marriage Registered domestic partner RDP Birth adoption or placement for adoption Loss of coverage because I turned 26 Involuntary loss of group coverage COBRA ended due to exhausting benefit Other Name change New name Old name New address please write new address in Section 3 Group name Subgroup Class Employee information First name M. I. Last name Social Security number Mailing address City Home phone Date of birth mm/dd/yyyy Primary language Changes English Medical coverage Special enrollment New policy/subscriber Add dependent on existing plan Plan change only COBRA Coverage State ZIP Gender M Date of employment mm/dd/yyyy F Email address Spanish Dependents Relationship code SP spouse DP domestic partner RDP registered domestic partner DP and RDP only if applicable to your plan Add Term Dependent first name Last Gender Relationship mm/dd/yyyy if different from employee SP DP RDP Child 1 Ward Enrollment will be delayed if fields with an asterisk are not filled out. 1 Please list only eligible dependent children* See Section 6 for dependent children qualifications. 9645512 1/15 BE-1141 over Other insurance coordination of benefits Will employee or any dependents have other insurance Yes No Dependent s not living with employee Are any of the dependent s not living with the employee If yes please provide the state and ZIP code. This is for informational purposes only and does not impact eligibility. Dependent name State ZIP Children are eligible to enroll for coverage through age 25. Please see your Member Handbook for additional eligibility information* The following are eligible dependent children Your or your spouse s natural or adoped child Children placed with you for adoption Newborns born to a covered dependent for whom you are financially responsible legal guardianship is required for coverage after the first 31 days Children related by blood or marriage for whom you are the legal guardian you will need to attach a signed court order showing legal guardianship Your domestic partner s natural child or adopted child if domestic partners by affidavit can enroll in your employer plan Your registered domestic partner s natural child or adopted child Authorization please read and sign below I acknowledge and understand my health plan may request or disclose health information about me or my dependents persons who are listed for benefits coverage on the enrollment form from time to time for the purpose of facilitating health care treatment payment or for the purpose of business operations necessary to administer health care benefits or as required by law.

Special enrollment form salve... Office of the Registrar Ochre Court Rm 203 100 Ochre Point Avenue Newport, RI 028404192 Tel: 4013412943 * Fax: 4013412996 SPECIAL ENROLLMENT FORM This form is required for all special enrollments

Fidelity account application e... Fidelity Investments Account Application/Enrollment Form 1. GENERAL INSTRUCTIONS Opening a new account: Please complete this form and sign it on the back. Once your account is established, you can

Ucb cares program enrollment f... NEW RENEWING80GRADUATE HWM DEPENDENT ENROLLMENT FORMAnthem Blue Cross Life and Health Insurance Company Berkeley SHIP 20182019 HWM GRADUATE DEPENDENT ENROLLMENT FORMUSI Student Insurance Medical ID#LAST

Amag assist reimbursement prog... Reset Form AMAG Assist Reimbursement Program Enrollment Form To enroll, please complete this form online and print it out OR print and complete by hand, then fax to AMAG Assist at 866 470 5871. If

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