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Consent for radiation therapy... CONSENT FOR RADIATION THERAPY TO THE VAGINAL CUFF/CERVIX/UTERUS WITH INTRACAVITARY BRACHYTHERAPY PATIENT NAME: Print name) MR#: TO THE PATIENT: You have been given information about your condition

Parent revoke consent for spec... Print on District Letterhead REVOCATION OF SPECIAL EDUCATION CONSENT Parent: If you wish to exit your child from special education, please complete this form and submit it to the District Office.

Assurance of consent for home... Department of Student Services MONTGOMERY COUNTY PUBLIC SCHOOLS Rockville Maryland 20850 ASSURANCE OF CONSENT FOR HOME INSTRUCTION PURPOSE This form is used by the Montgomery County Public Schools in accordance with the State Board of Education regulation Title 13A Subtitle 10 Home Instruction Chapter 01 General Regulations.

32 parental consent under 18 o... MARQUETTE UNIVERSITY OFFICE OF RESIDENCE LIFE UNDER 18 OVERNIGHT GUEST FORM Marquette University Residence Life Form #32 PARENTAL/GUARDIAN CONSENT AND MEDICAL INFORMATION Marquette Student Information

Authorization health form AUTHORIZATION TO CONSENT TO HEALTH CARE FOR MINOR (North Carolina General Statutes 32A-34) I, of County, , am the custodial parent having legal custody of , born , . a minor child, age I authorize

Consent to name change of mino... IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION Child(ren): Civil File No: Petitioner: And Respondent: CONSENT FORM The undersigned and are the (check one) parents guardians

Domestic violence order of pro... Case No. Court DOMESTIC VIOLENCE ORDER OF PROTECTION CONSENT ORDER General Court of Justice District Court Division County NORTH CAROLINA G.S. 50B-2, -3, -3.1 PETITIONER/PLAINTIFF Middle First Date

Blood transfusion consent form... PURPOSE OF TRANSFUSION: During your hospital visit your physician may order, or has ordered, a blood transfusion for you. Reasons for a blood transfusion or the use of blood products may include:

Nyc consent to dissolution 201... TM Finance REQUEST FOR CONSENT TO DISSOLUTION NYC DEPARTMENT OF FINANCE G COLLECTION DIVISION Instructions: Please complete, sign and date where indicated and mail to the address above. Under Section

Consent template combined hipa... Informed Consent Form and HIPAA Authorization Study Title: The Down Syndrome Growing Up Study IRB #: 09-007306 Version Date: December 8, 2009, Babette Zemel, PhD Telephone: 215-590-1669 The Children's

Invisalign consent form Informed Consent and Agreement for the Invisalign Patient Notice to treating office This form is to be signed by your Invisalign patients prior to treatment and kept for your records and should not be sent to Align Technology Inc. Patient s Informed Consent and Agreement Regarding Invisalign Orthodontic Treatment Your doctor has recommended the Invisalign system for your orthodontic treatment. I understand that I should only use the Invisalign products after consultation and prescription from an Invisalign certified doctor and I hereby consent to orthodontic prescribed by my doctor. Although orthodontic treatment can lead to healthy teeth and provide important benefits such as an attractive smile you should also be aware that orthodontic treatment including orthodontic treatment with Invisalign aligners has limitations and potential risks that you should consider before undergoing treatment. Device Description Invisalign aligners developed by Align Technology Inc* Align consist of a series of clear plastic removable appliances that move your teeth in small increments. Invisalign products combine your doctor s diagnosis and prescription with sophisticated computer graphics technology to develop a treatment plan which specifies the desired movements of your teeth during the course of your treatment. Upon approval of a treatment plan developed by your doctor a series of customized Invisalign aligners is produced specifically for your treatment. Procedure You will undergo a routine orthodontic pre-treatment examination including x-rays and photographs. Your doctor will take impressions of your teeth and send them along with a prescription to the Align laboratory. Align technicians will follow your doctor s prescription to create a ClinCheck software model of your prescribed treatment. Upon approval of the ClinCheck treatment plan by your doctor Align will produce and mail a series of customized aligners to your doctor. The total number of aligners will vary depending on the complexity of your doctor s prescription* The aligners will be individually numbered and will be dispensed to you by your doctor with specific instructions for use. Unless otherwise instructed by your doctor you should wear your aligners for approximately 20 to 22 hours per day removing them only to eat brush and floss. As directed by the series every two to three weeks. Treatment duration varies depending on the complexity of your doctor s prescription* Unless instructed otherwise you should follow up with your doctor at a minimum of every 6 to 8 weeks. Some patients may require bonded aesthetic attachments and/or elastics on their teeth during treatment to facilitate specific dental movements. Patients may require additional refinement after the initial series of aligners. Benefits to conventional braces. Aligners are nearly invisible so many people won t realize you are in treatment. Tooth movement can be visualized through the ClinCheck software. Aligners allow for normal brushing and flossing tasks that are generally impaired Aligners do not have the metal wires or brackets associated with conventional braces.

Consent minor form FIELD SERVICES 2701 S. DIRKSEN PKWY. SPRINGFIELD IL 62723 217-782-7044 www. cyberdriveillinois. com Office of the Secretar of State y vices Depar tment Driver Ser AFFIDAVIT / CONSENT FOR MINOR TO DRIVE I Driver s License/ID Number Name Telephone Number State and affirm that I am legally responsible for the below mentioned minor Date of Birth and that my relationship to the above-mentioned minor is Parent/Legal Guardian Other Responsible Adult If other responsible adult explain relationship I hereby certify and give my written consent to the Secretary of State for the issuance of a driver s license to the minor named on this affidavit. I certify that the above-mentioned minor has had 50 hours of behind-the-wheel practice time including 10 hours of night-time driving and that the minor is sufficiently prepared and able to safely operate a motor vehicle. Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure 735 ILCS 5/1-109 the undersigned certified that the statements set forth in this instrument are true and correct except as to matters therein stated to be on information and belief and as to such matters the undersigned certified as aforesaid that he/she verily believes the same to be true. Signature Address City State ZIP Code Subscribed and sworn to before me this day of 20. Notary Public My commission expires PLACE NOTARY SEAL HERE Printed on recycled paper. Printed by authority of the State of Illinois. August 2008 50M DSD X 174. 1 JESSE WHITE ILLINOIS SECRETARY OF STATE As a condition of obtaining my driver s license and as witnessed by my parent s or legal guardian s I hereby agree to the following rules. Failure to abide by any of these rules may result in the loss of my driving privileges for a period of time to be determined by my parent s or legal guardian s I will obey all traffic laws and drive with caution and patience observing the rules of the road as I have been taught. These laws include but are not limited to speeding and improper passing of a school bus. I will safely move over to the side of the road when encountering an oncoming emergency vehicle. I will always wear my safety belt while driving as required by law. I also will make sure my passengers wear their safety belts. For the first 12 months I have my license I understand that the law allows me to have only one passenger in my vehicle under age 20 unless the additional passenger is a sibling stepsibling child or stepchild of mine. Unless my parents say otherwise my parents and I are the only people allowed to drive my vehicle. There are absolutely no exceptions to this rule. I will never drive while under the influence of alcohol or drugs and I will never accept a ride from anyone who is under the influence of alcohol or drugs. I will not make or receive cell phone calls or text messages while driving. I will observe the nighttime driving restrictions of 11 p*m* to 6 a*m* Friday and Saturday and 10 p*m* to 6 a*m* Sunday through Thursday.

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