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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.

United states district court c... Sample Form 53 NAME. ADDRESS & TELEPHONE NUMBER OF AITORNEY(S) FOR, OR, PLA!NT!FF OR DEFENDANT!F PLA!NTlFF OR DEFENDANT!S PRO PER' AITORNEYS FOR: UNITED STATES DISTRICT COURT CENTRAL DISTRICT

Consent csc form 5. Consent I have read this document completely. I confirm that I understand that my use of the services of CSC is voluntary. CONSENT FORM AND TERMS OF USE FOR RESIDENTS OF THE UNITED STATES OF AMERICA FOR SERVICES OF Computer Sciences Corporation Inc. CSC 1. Version February 2013 Page 1 I give my consent to CSC to receive documents from me and collect personal information from me for use in applying for a Canadian visa permit or travel document. Or travel document application services unless I provide a further consent. I give my consent to CSC to disclose my personal information to the Consulate General of Canada in New York or Los Angeles and generally to the Government of Canada for the purpose of obtaining a visa permit or travel document and related services. CSC s service CSC makes available a Visa Application Centre VAC in New York City and Los Angeles in the United States of America in order to provide a service option designed to support better service to residents of United States of America* CSC is a Service Provider performing a number of functions on behalf of clients related to temporary resident visa and permit applications and applications for travel documents. The use of CSC s services is voluntary. Such service may also be sought directly from the Consulate General of Canada in New York or Los Angeles. CSC charges for its services have been approved by the Government of Canada* 2. Liability CSC is not an agent of the Government of Canada* CSC is a completely independent organisation operating under the laws of the United States of America and is solely responsible for the provision of its services. The Government of Canada will not accept liability for loss injury or claims of any kind including but not limited to breach of confidentiality of personal information arising out of the performance of CSC s services. The Government of Canada is not liable for the physical safekeeping and privacy of documents or personal information provided by clients or anyone else to CSC while such documents or information is in the possession or control of CSC or in the process of being transferred or transmitted to or from Canada* 3. Language of service CSC provides services in English and French. 4. Protection of personal information In order to obtain the authorisation of the Government of Canada as a service provider CSC has promised to respect principles of personal information protection adopted by various laws of Canada* Offices of CSC in the United States of America will make a copy of such principles available upon request. I understand that my use of the services of CSC is to assist me with submitting my temporary resident visa or permit application or application for travel documents and is on the terms and conditions noted in this document. The documents are my application form supporting or other documents as required by the Consulate General of Canada in New York or Los Angeles and my personal information required by CSC for its records that includes my name contact information nature of application/service sought and other elements as necessary.

New jersey dual agency form - NEW JERSEY ASSOCIATION OF REALTORS? STANDARD FORM OF INFORMED CONSENT TO DUAL AGENCY (BUYER) ? 2001, New Jersey Association of REALTORS?, Inc. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Dss 5169 consent of child for... STATE OF NORTH CAROLINA COUNTY CONSENT OF CHILD FOR ADOPTION (Stepparent Adoption) I, , being duly sworn, declare: 1. That I was born on the day of , , that my present address is ; 2. By executing

Tattoo consent release form PERMANENT COSMETICS/TATTOO CONSENT RELEASE FORM I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from. If single-use presterilized equipment is used please provide Lot/ID number. Signature Date Procedure description Artist W Data EH-PROGRAMS PROJECTS BODY ART FORMS WORD DOCS SAMPLE FORM - PERMANENT COSMETICS TATTOO CONSENT RELEASE FORM 3 11 14. I acknowledge that all my questions have been answered to my full and total satisfaction* I specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as follows I am not under the influence of alcohol or drugs. I do not have acne freckles moles or sunburn in the area to be tattooed that might be agitated by the tattoo process healing excluded. I have looked over my design checked the spelling if applicable and give my full consent to the application of my tattoo. I acknowledge that I am not pregnant. I am over eighteen 18 years of age. determine whether I might have an allergic reaction to the dyes pigments or processes used in my tattoo and I agree to accept that such risks are possible. take proper care of my tattoo and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my applied to my body. me as to the ability to later change alter or remove my tattoo. any actions or conduct of the associates agents or representatives of that are reasonable necessary to perform the tattoo procedure. I agree to release and forever discharge and forever hold harmless and its associates agents officers and shareholders from any and all claims damages or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by and its associates agents and representatives in the future. Administration and the health consequences of using these products are unknown* immediately notify the practitioner in the event I feel lightheaded dizzy and/or faint before during or after the procedure. I agree to follow all instructions concerning the care of my tattoo and that any touch-ups needed because of my own negligence will be done at my own expense. I have been fully informed of the risks of tattooing including but not limited to infection scarring difficulties in detecting melanoma and allergic reactions to tattoo pigment latex gloves and antibiotics. Having been informed of the potential risks associated with getting a tattoo I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing. I acknowledge that all my questions have been answered to my full and total satisfaction* I specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as follows I am not under the influence of alcohol or drugs. I do not have acne freckles moles or sunburn in the area to be tattooed that might be agitated by the tattoo process healing excluded.

Bcchp release and consent for... RELEASE AND CONSENT FOR BREAST AND CERVICAL CANCER TREATMENT FORM Please Print Clearly NAME Last First MI BCCHP PRIME CONTRACTOR SPOK Spokane Regional Health District BCCHP CLIENT ID # DATE OF BIRTH

Letter of consent application... Work Pass Division 18 Havelock Road Singapore 059764 www.mom.gov.sg Letter of Consent Application Form This form may take you 10 minutes to fill in. You will need the following information to fill

Physical therapy consent form ATI Physical Therapy Consent Form Consent to treatment I hereby grant consent for treatment or services to be provided by ATI Physical Therapy athletic training staff and team physicians. Disclosure of Protected Health Information I understand that my personal health information is protected by federal regulations under either the Health Information Portability and Accountability Act HIPAA or the Family Educational Rights and Privacy Act of 1974 FERPA and may not be disclosed without either my authorization or consent. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation* training staff for purposes of providing athletic training and medical services reporting and providing information and communications with coaches administrators physical therapists doctors and other allied health professionals. This authorization will allow athletic trainers to disclose medical information to coaches school officials and athletic directors on a need to know basis. This will ensure the safety of the athlete while participating in sports as well as establish a communication channel for coaches to stay abreast of an athlete s playing status and medical condition* Medical information shared between medical providers coaches and school administrators is confidential information and will not be shared to those outside these positions. I herby consent to and authorize ATI Physical Therapy s athletic trainers physical therapists and other health care personnel to disclose protected health information and any related information regarding an injury or illness during my training for purposes stated* I also consent to and authorize the release of protected health information to my parents or guardians. I also understand that the local regional and national media are not covered by HIPAA or FERPA and that these legal requirements will not apply. Expiration or Revocation athletics. I understand I have the right to revoke authorization at any time by sending written notification to ATI Physical Therapy s Director of Sports Medicine. Both the Athlete and Parent/Guardian Must Sign if under 18 years of age. Name of Athlete Signature of AthleteDate Name of Parent/Guardian Signature of Parent/GuardianDate. Disclosure of Protected Health Information I understand that my personal health information is protected by federal regulations under either the Health Information Portability and Accountability Act HIPAA or the Family Educational Rights and Privacy Act of 1974 FERPA and may not be disclosed without either my authorization or consent. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation* training staff for purposes of providing athletic training and medical services reporting and providing information and communications with coaches administrators physical therapists doctors and other allied health professionals. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation* training staff for purposes of providing athletic training and medical services reporting and providing information and communications with coaches administrators physical therapists doctors and other allied health professionals. This authorization will allow athletic trainers to disclose medical information to coaches school officials and athletic directors on a need to know basis.

Consent to obtain information... CONSENT TO OBTAIN INFORMATION University of Iowa Hospitals and Clinics FORM 1991 Hosp. #: Please PRINT (except signatures) and provide complete answers (information) in each section. Patient s Legal

Affidavit support consent form AFFIDAVIT OF SUPPORT AND CONSENT and SPECIAL POWER OF ATTORNEY I of legal age Filipino single/married to 1. I am/We are the father and/or mother of the minor s Name Age Said minor/s is/are applying for Philippine passport/s at the Department of Foreign Affairs I am/We are appointing presently residing at applying for a passport at the I/We authorize presently residing at of Social Welfare and Development for my/our child/children who will be travelling to his/her/their travel to I am/We are willing and able to support my/our child/children during the said travel On the said travel my/our child/children will be staying at Though the father/mother of said child/children is not here present I am giving consent to the above acts in as much as check one that applies said father/mother has earlier voluntarily and freely given his/her consent with no condition imposed whatsoever and requested that said consent be relayed by me. I have exclusive legal custody of minor single parent see attached divorce papers/death certificate of spouse I/We assume responsibility for the issuance of the passport and for allowing the trip of the said minor/s and further assume all obligations consequent thereto and I/We am/are executing this Affidavit to attest to the truth of the above statements and for whatever legal purpose this may serve. I have exclusive legal custody of minor single parent see attached divorce papers/death certificate of spouse I/We assume responsibility for the issuance of the passport and for allowing the trip of the said minor/s and further assume all obligations consequent thereto and I/We am/are executing this Affidavit to attest to the truth of the above statements and for whatever legal purpose this may serve.

Short form application for wri... 1998 National Association of Insurance Commissioners. SHORT .... Attach the following documents to this Application for written consent. Applications ... Application and I expressly consent and authorize

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