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response 93%

The Government welcomes the Committee’s Report as a valuable opportunity to consider the future direction and scope of the services that will be needed to prevent and treat allergies, within the framework of action to improve care for long-term conditions.

https://www.pdf-archive.com/2012/04/23/response/

23/04/2012 www.pdf-archive.com

Allergen Form 93%

Under this legislation, if you have one of the 14 allergies listed below it’s our responsibility to understand our foods and guide accordingly.

https://www.pdf-archive.com/2016/11/14/allergen-form/

14/11/2016 www.pdf-archive.com

12Informatin Reconciliatin 90%

Review of the patient’s known medication allergies.

https://www.pdf-archive.com/2017/01/23/12informatin-reconciliatin/

23/01/2017 www.pdf-archive.com

HealthForm2020 89%

❑ ADD ❑ADHD ❑ODD ❑Behavior Problems ❑ Anemia currently ❑ Asthma ❑ other Lung Disease ❑ Bed Wetting ❑ Frequent Urinary Infections ❑ Diabetes ❑ Ear Infections ❑ Tubes in Ears Currently ❑ Eating Disorders ❑ Anorexia/Bulimia ❑ Obesity ❑ Epilepsy ❑ Absence Spells ❑ Grand Mal Seizures ❑ Hay Fever/Seasonal Allergies ❑ Hypertension ❑ Heart Disease ❑ Mental Health Concerns ❑ Anxiety Disorder ❑ Depression ❑ Bipolar Disorder ❑ Menstrual Concerns LMP prior to camp __/__/__ ❑ Sleep Walking ❑ Sleep Talking ❑ Sprains, Strains, Muscle, Bone or Joint Problems ❑ Stomach problems ❑ Diarrhea ❑Constipation ❑ Other diagnosis or concerns:___________________ _____________________________________________ Explain conditions checked above including required medications, treatments, special restrictions or considerations while at camp:

https://www.pdf-archive.com/2020/01/23/healthform2020/

23/01/2020 www.pdf-archive.com

abundantvinecsa 87%

$10 Share (you get varying items from your categories you picked above, worth share amount) My choice (I want to purchase items indivually, please send me a price list) Do you have any dietary concerns or allergies?

https://www.pdf-archive.com/2015/07/30/abundantvinecsa/

30/07/2015 www.pdf-archive.com

MOPS at BRCC Registration 86%


 
 
 MOPS
@
BRCC
Registration
 7480
West
US
Hwy
52


•

New
Palestine,
IN


46163

•

317.861.3880
 
 ________________________________________________________________________________________________________
 Last
Name
 
 
 
 
 First
Name
 
 
 
 
 M.I.
 
 _________________________________________________________________________________________________________
 Address
 
 _________________________________________________________________________________________________________ City
 
 
 
 
 
 State
 
 
 Zip
Code
 
 _________________________________________________________________________________________________________ Home
Phone
 
 
 
 
 Cell
Phone
 
 _________________________________________________________________________________________________________
 Email
 
 Marital
Status:

Single



Married



Divorced



Widowed
 Husband’s
Name
(if
applicable):
_________________________________
Anniversary:
__________________
 Prior
MOPS
Member:

No



Yes,
at
BRCC



Yes,
somewhere
else
 Do
you
attend
church?:

No



Yes,
at
BRCC



Yes,
__________________________________________
 How
did
you
find
out
about
MOPS
at
BRCC?
______________________________________________________
 Please list ALL of your children’s names & birthdates:  (Please
fill
out
the
back
for
each
child
who
will
be
in
the
MOPPETS
program.)
 
 _________________________________________________________________________________________________________ Name
 
 
 
 
 
 Gender
 
 
 Birthdate
 
 _________________________________________________________________________________________________________ Name
 
 
 
 
 
 Gender
 
 
 Birthdate
 
 _________________________________________________________________________________________________________ Name
 
 
 
 
 
 Gender
 
 
 Birthdate
 
 _________________________________________________________________________________________________________ Name
 
 
 
 
 
 Gender
 
 
 Birthdate
 
 If
you
are
pregnant,
when
is
your
due
date?
______________________________________________________
 
 Please
note,
there
is
a
space
limitation
in
MOPS
based
on
volunteer
availability
in
the
MOPPETS
program.

You
 will
receive
a
notice
confirming
the
receipt
of
your
registration.

We
will
inform
you
by
September
3,
2010
in
 regard
to
your
registration
status
(accepted
or
on
waiting
list).

Thank
you
for
understanding.
 
 
 
 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
MOPS
Group
Only
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
 Date
Received:
_______________________

Date
Registration
Fee
($20.00)
Received:
_______________
 Discussion
Group
Assigned:
________________________________________________________________________
 
 
 
 
 
 
 MOPPETS
at
BRCC
Registration
 
 7480
West
US
Hwy
52


•

New
Palestine,
IN


46163

•

317.861.3880
 Please list only the children who will be in the MOPPETS program.  
 Child’s Name (Last, First, M.I.):
___________________________________________________________________
 Birthdate:
__________________________________________________
Gender:

Boy



Girl
 Address
(if
different
from
mother’s):
_____________________________________________________________
 Additional
Emergency
Contact:
___________________________________________________________________
 Phone
Number:
____________________________________
Relationship:
________________________
 Allergies/Important
Information:
________________________________________________________________
 
 Child’s Name (Last, First, M.I.):
___________________________________________________________________
 Birthdate:
__________________________________________________
Gender:

Boy



Girl
 Address
(if
different
from
mother’s):
_____________________________________________________________
 Additional
Emergency
Contact:
___________________________________________________________________
 Phone
Number:
____________________________________
Relationship:
________________________
 Allergies/Important
Information:
________________________________________________________________
 
 Child’s Name (Last, First, M.I.):
___________________________________________________________________
 Birthdate:
__________________________________________________
Gender:

Boy



Girl
 Address
(if
different
from
mother’s):
_____________________________________________________________
 Additional
Emergency
Contact:
___________________________________________________________________
 Phone
Number:
____________________________________
Relationship:
________________________
 Allergies/Important
Information:
________________________________________________________________
 
 Child’s Name (Last, First, M.I.):
___________________________________________________________________
 Birthdate:
__________________________________________________
Gender:

Boy



Girl
 Address
(if
different
from
mother’s):
_____________________________________________________________
 Additional
Emergency
Contact:
___________________________________________________________________
 Phone
Number:
____________________________________
Relationship:
________________________
 Allergies/Important
Information:
________________________________________________________________
 
 To register additional children, please attach another MOPPETS registration form. 

https://www.pdf-archive.com/2011/07/28/mops-at-brcc-registration/

28/07/2011 www.pdf-archive.com

IJRI-ES-01-001 AIR QUALITY ANALYSIS IN THE CITY OF HYDERABAD 83%

This air we breathe may cause allergies in various people who are susceptible to the pollutants.

https://www.pdf-archive.com/2016/06/28/ijri-es-01-001-air-quality-analysis-in-the-city-of-hyderabad/

28/06/2016 www.pdf-archive.com

Cafe-D'Alsace Menu-English 80%

Please make us aware of any special dietary requirements or allergies you may have.

https://www.pdf-archive.com/2018/03/07/cafe-d-alsace-menu-english/

07/03/2018 www.pdf-archive.com

generator 77%

03/15/2018 Allergies or side effects: Allergies:

https://www.pdf-archive.com/2018/03/15/generator/

15/03/2018 www.pdf-archive.com

Revive Order Form 74%

Allergies or Dis-Likes:

https://www.pdf-archive.com/2011/12/12/revive-order-form/

12/12/2011 www.pdf-archive.com

Group menus 11.14 74%

water included) SUPPLEMENTS Laborum Torrontes 2012, Cafayate, Salta | Glass £11.50 Malamado Port style Malbec 2012 - 19.5%, Agrelo, Gl 100ml £6.95 Bianchi sparkling Brut | Glass £7.95 Espresso Martini £7.50 Château du Breuil Fine Calvados | Glass 50ml £5.50 Hennessy Cognac VS | Glass 50ml £10.95 Those with dietary requirements or food allergies, please ask for the Manager An optional 12.5% service charge will be applied to your bill.

https://www.pdf-archive.com/2014/11/08/group-menus-11-14/

08/11/2014 www.pdf-archive.com

visual dictionary- kitchen-12-16-suze 74%

Kitchen Cozinha Allergies Do you have allergies?

https://www.pdf-archive.com/2016/10/23/visual-dictionary-kitchen-12-16-suze/

23/10/2016 www.pdf-archive.com

Sheet 74%

N9KS-YJAG-MPCP-CKYS-NFEN *N9KSYJAGMPCPCKYSNFEN* Allergies Name Reaction Allergy to penicillin hives (red, raised, itchy bumps) First observed Conditions You don't have anything listed here yet.

https://www.pdf-archive.com/2017/11/25/sheet/

25/11/2017 www.pdf-archive.com

Carlson 2015 Permission Form 74%

__________________ ALLERGIES AND MEDICAL CONDITIONS Please list any allergies or medical conditions that our staff should be made aware of:

https://www.pdf-archive.com/2015/09/18/carlson-2015-permission-form/

18/09/2015 www.pdf-archive.com

Group menus 74%

 Brut  Bianchi,  Traditional  method,  San  Rafael,  Mza  |  Glass  £7.95 Expresso  Martini  £7.50 Remy  Martin  Cognac  VSOP  |  Glass  50ml  £10.95 Château  du  Breuil  Fine  Calvados  |  Glass  50ml  £5.50 Those  with  dietary  requirements  or  food  allergies,  please  ask  for  the  Manager An  optional  12.5%  service  charge  will  be  applied  to  your  bill.

https://www.pdf-archive.com/2014/11/02/group-menus/

02/11/2014 www.pdf-archive.com