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Form preview Form school order Maryland State Management of Diabetes at School/Order Form This order is valid only for the Current School Year including summer session Student DOB School Grade CONTACT INFORMATION Parent/Guardian Home Phone Work Cell/pager Other Emergency Contact Orders complete only if is needed at school 1. With student With teacher If most recent blood glucose is less than exercise can occur when blood glucose is corrected and above. Eat grams of carbohydrate Before Every 30 mins during After vigorous exercise Avoid exercise when blood glucose is greater than or ketones are Bus Transportation Check blood glucose 15 minutes prior to boarding bus Allow student to eat on bus if having symptoms of low blood glucose Provide care as follows Student can self-perform the following procedures school nurse and parent must verify competency Measuring Injecting Determining dose Independently operating pump Disaster Plan if needed for lockdown 24 hr shelter in place Follow orders as on Management Form Additional orders as follows Administer long acting as follows Other instructions Parent s Signature Pump Resource Person Phone Pump Management Type of pump Start Date for Pump Therapy Type of in pump 12am to /carbohydrate ratio Hyperglycemia Comment Check Management of Diabetes at School Order or correction factor Pump site should be changed if BG greater than times should be given by syringe or pen if needed Management Skills of Student As verified by school nurse health care provider and parent Count carbohydrates yes no Bolus an dose Reset basal rate profiles Set a temporary basal rate Disconnect pump Reconnect pump at infusion set Prepare infusion set for insertion Insert infusion set Troubleshoot alarms and malfunctions Give self injection if needed Change batteries Student is non-independent Child Lock On Yes No Pump Supplies Extra supplies needed include Infusion sets reservoir/cartridges insertion device vial syringes batteries Location of supplies doses as follows MSDE8/10. administration via Syringe and vial pen pump Other Type of pump Basal rates 2. Before Lunch/Meals Name of Routine lunchtime dose Per sliding scale as follows Meals Blood Glucose to give units Calculated dose add carbohydrate coverage and correction dose for total dose Carbohydrate Coverage to carbohydrate ratio Give unit s pergms carbohydrate. Correction Subtract units for every mg/dl of glucose below mg/dl may be given after lunch if 3. Other times may be given Calculated as above. Snack Dose Ketones If ketones are Give/Add unit s Give Health Care Provider Authorization for Management of Diabetes in School My signature below provides authorization for the above written orders. This authorization is for a maximum of one school year. If changes are indicated I will provide new written authorization which may be faxed* Address City Zip Phone Fax Use for Prescriber s Address Stamp Parent Consent for Management of Diabetes at School I We request designated school personnel to administer the medication and treatment orders as prescribed above.
Form preview Aviva foundation form Aviva Charitable Foundation Grant Application www. avivausa.com 7700 Mills Civic Parkway West Des Moines IA 50266-3862 INSTRUCTIONS 1. 8. Are you affiliated with any other local or national agencies please list 9. Have you previously received support from Aviva Charitable Foundation If no state. Annotated board of directors list. Submit completed Application and Attachments to Karen Lynn Aviva Charitable Foundation Mailing Address Email AvivaFoundation avivausa.com. Do not delete or alter any selection* 2. Do not change the order of the information* 3. Information required is shown in yellow boxes do not alter text in yellow boxes. 4. Provide your organization s information in white boxes. 5. Attach additional sheets if necessary. 6. It is not necessary to print and submit your Application in color. BACKGROUND Date of Grant Request Organization Name Federal Tax Identification Number Address City State Zip Code Contact Person Title Email Address Phone Type of support requested Requested amount Program category Program Grant Operating Expenses Arts Culture Civic Community Education Is your organization a member of the United Way targeted market areas Des Moines IA Topeka KS Melville NY 17935 Yes Street to School Health Human Services No If no the grant request is probably not eligible for funding ver. 8/12 Page 1 of 4 REQUEST statement. 2. Describe the project/program for which support is requested* 3. Dates and length of project/program* 4. Assets your organization possesses that enhance the 5. Describe the goals of the program for which support is requested* 6. Describe how this program will be evaluated* 7. Describe the clients and geographical area your program serves. If yes please describe and state date of funding. 10. Are Aviva employees active participants and/or volunteers in yes please list their names. 11. Why should Aviva provide support for this request ver. 8/12 Page 2 of 4 BUDGET Total Program Total Organization 13a* Current fiscal-year budget Expenses Income Fund Balance 13b. Last fiscal-year budget 14. Total annual revenue from your last fiscal year 15. List your three largest contributors name / amount 16. Sources of Income Corporations Government Individuals Programs How much is spent in this community To national organization 19. Is your organization carrying a deficit If no please list amount of current operating reserve or endowment. If yes please describe. 20. Identify additional sources of support that are or will be available for the balance of the program budget. of budget Fees Services Interest income Benefits/Special Events Other Total Operating Ratios Administration Fund-raising of total No OTHER 21. Other information that is helpful in reviewing your application* ATTACHMENTS Please attach the following documents to this application IRS 501 c 3 determination letter. Do not delete or alter any selection* 2. Do not change the order of the information* 3. Information required is shown in yellow boxes do not alter text in yellow boxes. 4. Provide your organization s information in white boxes. 5. Attach additional sheets if necessary.
Form preview Standard form apartment lease... G R E A T B O S N L D STANDARD FORM APARTMENT LEASE SIMPLIFIED FIXED TERM Date This is a Lease of Apartment No. Located in a Building Numbered in Massachusetts. The Landlord is whose address is SA M PL The term of this lease is beginning on and ending on Landlord and Tenant agree that each of them has various rights and duties and that this Lease is subject to certain conditions as follows FOR MAINTENANCE THE TENANT SHOULD CONTACT Name Telephone Street Address City State Zip To be filled in only where maintenance is performed by Managing Agent. TENANT This section governs rent payments. In some cases rent payments may increase during the lease term* Please be sure that you carefully read and understand this section* Please initial here when you are certain that you understand and agree with this section* payments. Be sure to discuss with the Landlord those payments which will be required of you for this Apartment 1. RENT a On or before the first day of every month in advance the Tenant must pay the monthly rent which is. the Building as well as the land on which it is located* Real estate taxes are assessed on a fiscal year basis and each fiscal year begins on July 1 and ends on the following June 30. The most recent tax bill received by the Landlord was for the fiscal year ending June 30 but real estate taxes may be higher in later fiscal years. If this happens the Tenant will be required to pay of the increase. This payment which is considered additional rent will be prorated if this Lease is not in effect throughout the entire fiscal year in which the tax increase occurs. The Landlord will notify the Tenant of any tax increase and will explain how the Tenant s share is to be paid* The Tenant s share of any tax increase must always be in proportion to the relationship between 1 the apartment and 2 the whole of the real estate being taxed namely the Building and the land on which it is located* If the Landlord obtains an abatement or refund of the real estate tax levied on the whole of the real estate a proportionate share of the abatement or refund less reasonable attorney s fees if any must be refunded to the Tenant. 2. HEAT AND UTILITIES Landlord will furnish all required heat hot water fuel oil and utilities to the Apartment with the following exceptions. First the Tenant must make all service arrangements and pay all bills for telephone as well as gas electricity and water and sewer service if checked* Gas or electricity should be checked only if the Tenant s usage is measured by a separate meter which has already been installed in which case it will also be the Tenant s responsibility to make all necessary service arrangements. Water and sewer service should be checked only if a the Tenant s usage is measured by a separate meter or submeter which has already been installed and b a Water and Sewer Submetering Addendum has been signed by make all necessary service arrangements and pay all bills for fuel oil which is provided through a separate oil tank and used to supply heat and/or hot water only to the Apartment.
Form preview Sdsu letter recommendation for... Letter of Recommendation Doctor of Physical Therapy Program School of Exercise Nutritional Sciences 5500 Campanile Drive San Diego CA 92182-7251 619. 594-0556 619. 594. 6553 Fax Applicant Instructions An appropriate reference is an Recommendation experienced credentialed professional who is able to comment on your ability to succeed in a graduate program* The reference should have no conflicting relationship e*g* subordinate or family. Complete the top of this form in ADOBE READER Print a hard copy and sign at Applicant Signature Give the signed copy to the evaluator with a self-addressed envelope. The evaluator should return the completed form directly to you in a signed sealed envelope to be included in your application packet that you will submit to the SDSU DPT program* Name Last First Middle Date of Birth mm/dd/yy Degree Program Doctor of Physical Therapy I agree this recommendation letter shall be held in confidence by the officials of San Diego State University and I hereby waive any right to examine it Applicant Signature Yes No Date Reference Instructions The person named is applying to San Diego State University for the Doctor of Physical Therapy degree. This form is submitted for your frank evaluation of the applicant. Please enclose the completed and signed evaluation in an envelope placing your signature over the sealed flap* Return the completed evaluation in the sealed envelope to the applicant. Name and Credentials Organization Street Address City State Zip Email Address Daytime Phone Page 1 of 4 In what capacity do you know the applicant How long have you known the applicant Years Months Some gifted individuals achieve marginal scholastic records. In your opinion is the applicant s scholastic record as you know it an accurate index of his or her scholastic ability If No please explain In your opinion what is the applicant s likelihood of completing the degree requirements for the DPT program at San Diego State University Not very Likely Neutral Very likely. A substantial portion of the coursework is completed independently. The following questions deal with this specific aspect of the University s pedagogical model* Please place an X in the corresponding response to each statement ensuring none are left unanswered* Outstanding Average With Difficulty Ability to set own goals/timelines Ability to accomplish goals within established timelines Ability to seek help and/or guidance as needed Ability to establish relationships with faculty/colleagues Please rate the applicant in terms of the following qualities Superior Top 2 Top 10 Excellent Good Poor Lower No basis for judgment. Intellectual and academic ability Analytical ability Ability to work well with others Tenacity perseverance toward goals Motivation for academic study by established deadlines Maturity and judgment. Accepts responsibility for own actions Integrity Self-confidence Ability to accurately self-assess Leadership ability Clinical potential Research potential Teaching potential Written expression Oral expression San Diego State University assumes that in all likelihood the applicant is a competent person* We would be most appreciative if instead of describing his/her general excellence you would tell us what makes this candidate especially promising for graduate study.
Form preview Fha amendatory clause form 200... FHA Amendatory Clause Real Estate Certification Borrower Name s Borrower Address Property Address FHA Case Number FHA AMENDATORY CLAUSE It is expressly agreed that notwithstanding any other provisions of this contract the purchaser shall not be obligated to complete the purchase of the property described herein or to incur any penalty by forfeiture of earnest money deposits or otherwise unless the purchaser has been given in accordance with HUD/FHA or VA requirements a written statement issued by the Federal Housing Commissioner Department of Veterans Affairs or a Direct Endorsement Lender setting forth the appraised value of the property of not less than. The purchaser shall have the privilege and option of proceeding with consummation of the contract without regard to the amount of the appraised valuation* The appraised valuation is arrived at to determine the maximum mortgage the Department of Housing and Urban Development will insure. HUD does not warrant the value or the condition of the property. The purchaser should satisfy himself/herself that the price and condition of the property are acceptable. Borrower Date Seller REAL ESTATE CERTIFICATION The borrower seller and the selling real estate agent or broker involved in the sales transaction certify that the terms and conditions of the sales contract are true to the best of their knowledge and belief and that any other agreement entered into by any of the parties in connection with the real estate transaction is part of or attached to the sales agreement. The purchaser shall have the privilege and option of proceeding with consummation of the contract without regard to the amount of the appraised valuation* The appraised valuation is arrived at to determine the maximum mortgage the Department of Housing and Urban Development will insure. HUD does not warrant the value or the condition of the property. The purchaser should satisfy himself/herself that the price and condition of the property are acceptable. HUD does not warrant the value or the condition of the property. The purchaser should satisfy himself/herself that the price and condition of the property are acceptable. Borrower Date Seller REAL ESTATE CERTIFICATION The borrower seller and the selling real estate agent or broker involved in the sales transaction certify that the terms and conditions of the sales contract are true to the best of their knowledge and belief and that any other agreement entered into by any of the parties in connection with the real estate transaction is part of or attached to the sales agreement. The purchaser shall have the privilege and option of proceeding with consummation of the contract without regard to the amount of the appraised valuation* The appraised valuation is arrived at to determine the maximum mortgage the Department of Housing and Urban Development will insure. HUD does not warrant the value or the condition of the property. The purchaser should satisfy himself/herself that the price and condition of the property are acceptable. Borrower Date Seller REAL ESTATE CERTIFICATION The borrower seller and the selling real estate agent or broker involved in the sales transaction certify that the terms and conditions of the sales contract are true to the best of their knowledge and belief and that any other agreement entered into by any of the parties in connection with the real estate transaction is part of or attached to the sales agreement.
Form preview Usda final title opinion form USDA-RD Form-RD IL 1927-10 Rev. 09-08 OGC-CHI FINAL TITLE OPINION Loan Applicant Address of Property Applicant for Title Examination County State I. I have examined title to the property described in the attached schedule A. My examination covered the period from the time of termination of title search covered by my Preliminary Title Opinion on Form RD IL 1927-9 or the time of recordation of the initial loan security instrument if this opinion covers land already owned by the loan applicant a subsequent loan case to date at time including the time of filing the current security instrument. II. Based on said title examination my preliminary title examination if any and any additional information concerning the title which has come to my attention it is my opinion that A. Good and marketable title in accordance with title examination standards prevailing in the area to said property real estate and any water rights offered as security is now vested in B. The United States of America holds a valid mortgage lien on said property as required by the United States Department of Agriculture which lien was filed for record Book page and office C. Said property and lien are subject only to encumbrances. reservations exceptions and defects which were approved by written administrative waivers of the United States of America attached hereto or to my Preliminary Title Opinion* III. The term encumbrances reservations exceptions and defects means all matters which would prevent the United States from obtaining the required lien on the property identified in paragraph I including but not limited to a mortgages deeds of trust and vendors mechanics materialmen s and all other liens including any provisions thereof for future advances which could take priority over the said lien to the United States b Federal State and local taxes including county school improvement water drainage sewer inheritance personal property and income c State and Federal bankruptcy insolvency receivership and probate proceedings d judgments and pending suits in State and Federal courts e recorded covenants conditions restrictions reservations liens encumbrances easements rights-of-way leases mineral oil gas and geothermal rights regardless of the right of surface entry timber rights water rights pending court proceedings and other matters of record which affect the title of the property or the ability of the buyer or seller to convey or accept title. IV. This opinion is issued expressly for the benefit of the above-named applicant for title examination and the United States of America acting through the United States Department of Agriculture Agency which provided the assistance and I assume liability to each hereunder. I have examined title to the property described in the attached schedule A. My examination covered the period from the time of termination of title search covered by my Preliminary Title Opinion on Form RD IL 1927-9 or the time of recordation of the initial loan security instrument if this opinion covers land already owned by the loan applicant a subsequent loan case to date at time including the time of filing the current security instrument. II. Based on said title examination my preliminary title examination if any and any additional information concerning the title which has come to my attention it is my opinion that A.

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