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Procedure, the Grievance Form is for use in filing a grievance when a satisfactory
resolution is not achieved through a formal appeal. Please note that this form and any
supporting documentation must be properly completed, received, and on file in the
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correspondence disclosing the appeal committee's decision, otherwise, the grievance
will no longer be eligible for review. Students are encouraged to submit the Grievance
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Cardinal Station Newburg Center for Primary Care
215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205
Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208
I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components
UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
enclosing several forms and ask that you completely fill each form out.
The first sheet will help us learn more about you; please completely fill out this
form about your family history. The next sheet is titled, "Authorization for the
use and/or Disclosure of Protected Health Information", and you will need to
completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
medical facilities.
Following, please completely fill out the Registration, Social Services & Consent
Form. Next, you will find our Privacy Notice, followed by an acknowledgement that
you have received and understand our Privacy Policies. Finally, the last form is the
Office Acknowledgements and Policies form. Please read carefully and sign
your name at the bottom of the letter.
Please make sure to bring all of these forms with you to your first office visit.
Do not mail them back to the office. Also, please remember to always
bring your picture ID, current insurance cards and your co-payment. If your
health insurance requires you to select a primary care doctor please do so prior to
your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
If the patient is under 18 years of age he or she must be accompanied by an
adult and will need to bring a copy of their current immunization certificate.
Please arrive 15 minutes ahead of your scheduled appointment time so that if
you have questions about these forms or we need more information, we can
address it all prior to your appointment.
We look forward to seeing you!
University of Louisville Physicians
UofL Family and Geriatric Medicine

----7YWnLwG0;GGosqG DearTeacher Coach, Thank you for participating in the What'sSo Cool About Manufacturing? Educational Media Contest! The eMediaWorkshop Training Series contains six short programs designed to guide students through the process of educational media production. This Training Guide will help you successfully lead your student teams by providing: 1. Instruction materials about the production process. 2. Interactive worksheets for each section. 3. Equipment information and tips for proper operation. 4. Rules and regulations for the contest. 5. Contest Timeline and Teacher Coach Checklist. 6. Optional practice activities. 7. Waivers and Release forms. 8. Pennsylvania State Standards Alignment. We anticipate that the time and effort your students spend researching and producing this film will open their eyes to the world of career opportunities in innovative manufacturing environments. If you have any questions or comments, don't hesitate to contact: Jason Fink (570) 320-4213 jfink@williamsport.org or Sharon Jones (570) 320- 4202 or sjones@williamsport.org We look forward to finding out What's So Cool About Manufacturing with you and your student team this fall! Best of luck! The WSCM Team

Newsletter 5

Work Hard

Be Nice

Show Character

Year 4 have been very busy, filling a lot of learning into only 5 school weeks! We have learnt about the Romans and how they conquered the Celts and settled in Britain, building their grand houses, called villas. There is even the remains of a Roman Villa on the Long Cross! We imagined what the Romans were like who lived in Lawrence Weston! We learnt that the Romans were fantastic inventors, inventing many things that we use today, such as central heating, newspapers and even air conditioning! In Term 1, Year 4 learnt about the Ancient Greeks and they enjoyed planning and making their own Greek pot made from a flower pot! This term, we have planted sunflower seeds in these pots and we are enjoying watching their progress. Ronnie's sunflower is the tallest at the moment, measuring 64cm! The children will bring these sunflowers home in Term 6, so they will need somewhere to plant them as they might grow to be over 2 metres tall! Miss Owen.

Dear Parents, Carers & Friends,

Welcome to our Term 5 Newsletter. Whilst the term has been really short, we've managed to pack a great deal in! There have been some brilliant trips (with more to come after half-term) and again pupils across the school have worked really hard - it is an absolute privilege for me to get to walk into the classrooms in which your children are working and see the level of detail and rigor with which they are being taught.

I think I've said it every term this year, but I must, again, say a huge collective ''thank you" to parents and carers for the level of attendance this year. It's brilliant: it's giving children the very best chance of success.

We hope that you all get to have a pleasant and peaceful week with your children.

We'll see them and you back here on Monday 3rd June 2019 for Term 6.

Best wishes,

David Wayland, Principal.

TERM DATES 2019/20

Term From Until

1 Mon. 2nd Sept. 2019

(INSET days – Mon. 2nd Sept. & Fri. 11th Oct. 2019) Fri. 25th Oct. 2019

2 Mon. 4th Nov 2019 Fri. 20th Dec. 2019 3 Mon. 6th Jan. 2020

(INSET day - Mon. 6th Jan & Fri. 14th Feb 2020) Fri. 14th Feb. 2020

4 Mon. 24th Feb. 2019 Fri. 3rd April 2020 5 Mon. 20th April 2020 Fri. 22nd May 2020 6 Mon. 1st June 2020 Fri. 17th July 2020 Year 1 have had a

fun term

learning about

our new book

'Dear Teacher'.

The book has

deepened our

knowledge of

how to write letters and we have enjoyed writing to Michael and Miss Brooks from the book. We have started to bring a real focus into our handwriting during our Literacy lessons which has made some of our work really presentable. We have

been learning all about planes and how they fly and we also looked at famous pilots such as Amelia Earhart and the Wright brothers. Year 1 had a fantastic time during our trip to Aerospace where we were able to reinforce our learning about how planes fly - we even got to go in a Concord! We are developing more in our Maths Mastery lessons and have enjoyed understanding the concept of money and how much things are worth. Year 1 have produced lovely pieces of Art including aeroplanes made out of plastic bottles and collages of the sky. Miss Baker

Ahoy! From Year 3. This term we have been reading our first chapter book: 'Kensuke's Kingdom' by Michael Murporgo. The story follows the journey of Michael and his parents as they sail around the world. We have coupled this with our geography topic. Year 3 have learnt about the different types of geography, how to use cardinal and intermediate directions to describe where the major cities are in the UK and which are the highest peaks and longest rivers in the UK. Year 3 have also continued their learning in music by learning to play a jazz music piece in the style of Duke Ellington. Bristol Sport PE sessions have also continued with an outstanding gymnastic coach who has had all the children trying handstands, cartwheels and back flips. Mrs White.

The Nursery topic this term has been "new life".

We explored eggs, feeling eggs and thinking about what might be inside. We also cooked our own scrambled eggs. We have learnt a lot about caterpillars and have been looking after our own.

Our caterpillars have now turned into chrysalises, we are waiting for them to emerge as beautiful butterflies. We are also going to visit the farm on the last week of term.

Mrs Fitz-Gerald

School uniform now needs to be purchased online from: www.myclothing.com

Please sign the Change.org petition to help improve road safety for children and families crossing Long Cross.

www.change.org/p/bristol-city-council-bank-leaze-safe-school-crossing Oasis Academy Bank Leaze has lost the school crossing patrol over Long Cross, a busy 30mph road . At this junction, cars come from three sides (Long Cross and Chapel Lane), making it dangerous to cross with children.

Class Attendance

Whole School (excluding nursery and reception) 96.7%

0.7% higher than most schools

Nursery

85.6%

Year 3

98.3%

2.3% higher than most schools

Reception

95.1%

0.9% lower than most schools

Year 4

97.0%

1.0% higher than most schools

Year 6

97.1%

1.1% higher than most schools

Year 5

95.7%

0.3% lower than most schools

Year 2

97.0%

1.0% higher than most schools

Year 1

95.1%

0.9% lower than most schools

100% Attendance

WELL DONE to the following pupils for coming to school on time, every day this year!

(Correct 21/05/2019)

Aaron (Y2) Harvey (Y4) Lottie (Y6)

Adam (Y3) Issac-Eddie (Y2) Mantas (Y6) Aiyonia (R) Jacob (Y3) Max (R)

Alisha (Y2) James-Lee (Y6) Megan (Y4) Amelia (Y3) Keira (Y3) Mia (Y2)

Ellie (Y6) Kiera (Y5) Michael (Y2)

Erin (Y2) Lataya (R) Tirion (Y6)

Fatou (Y1) Leon (Y3)

Harrison (Y5) Liana-May (Y3)

----MU4ADPjm;SWQWZV

Dear Valued Guest,

Welcome and thank you for choosing Alpenglow Short Stay Assisted Living as your place of recovery!

Alpenglow is designed to streamline the recovery process by alleviating some of the stressors of surgery, launching your physical therapy, providing education and inspiration, and teaching you daily living skills you'll need to continue your recovery at home.

The Alpenglow staff is a multidisciplinary team of highly skilled orthopedic professionals.

We will assist you with activities of daily living and pain management — while empowering you to become an active partner in your recovery.

After all, recovering from surgery is hard work.

Your doctor will encourage you to start using your new hip almost immediately. Initial movement may be difficult and uncomfortable but it is crucial to an optimal recovery. We will give you support and encouragement but ultimately, you are the vital link in the successful outcome of your surgery.

Please use this guide as a tool to help you through your pre- and post-surgical process. It contains important details regarding your surgical experience, post -op care, physical therapy activities and frequently asked questions and answers.

Again, thank you for choosing Alpenglow Short Stay Assisted Living. We look forward to working with you soon on your way to achieving a pain free, independent and all around better quality of life!

Sincerely,

Overview .................................................................................................................. A1 Pre-op Exercises ....................................................................................................... A2 Long Term Prep Work ............................................................................................... A5 Dental work, Exercise, Smoking, Nutrition, Alcohol, Arranging for Help, Equipment Near Surgery Day Prep.............................................................................................. A7 Illness, Medications, Diabetic Supplies, Preventing Infection Preparing Your Home Checklist ............................................................................... A9 Night Before Surgery Checklist................................................................................ A10 Day of Surgery Checklist ......................................................................................... A11 Day of Surgery Process............................................................................................ A12 B. Your Alpenglow Stay

Admission Details ..................................................................................................... B1 Early Activity............................................................................................................. B1 Eating & Drinking...................................................................................................... B1 Managing Pain, Cold Therapy, .................................................................................. B2 Coughing & Deep Breathing ..................................................................................... B2 Constipation, Discharge ............................................................................................ B3 C. Post-Op Activities: Physical Therapy, Daily Activities & Exercises What to Expect Following Hip Surgery...................................................................... C1 Post-op Therapy Progression ........................................................ ............................. C2 Therapy Do's and Don'ts .......................................................................................... C3 Daily Activities.......................................................................................................... C4 Your Physical Therapy Plan & Additional Handouts................................................ C21 D. Going Home

Pain Management .....................................................................................................D1 Showering/Bathing ....................................................................................................D2 Caring for Your Incision ............................................................................................D2 Decreasing Your Risks...............................................................................................D2 For Lung Complications, Blood Clots & Infection

E. Resources

Frequently Asked Questions.......................................................................................E1 Helpful Links..............................................................................................................E3 American Joint Replacement Registry Letter ...............................................................E4 Herbal Supplements to Avoid.....................................................................................E5 A: Preparing for Surgery

Your diet will be advanced as tolerated as soon as you are tolerating beverages and food; this means you will begin by taking small sips of water or clear liquids. If you do not experience any nausea, your intake will gradually be increased until you are able to tolerate solid foods. Meals are provided three times a day for Alpenglow residents. We will have snacks and juices available upon request.

Alpenglow Academy |Your Stay at Alpenglow, Page B2

Managing Your Pain

Post-surgical pain is a complex response to tissue damaged during surgery; both bone and tissue are undergoing a healing process that will not be complete for several months after your operation. There are many avenues of pain relief including cold therapy, pain medications or alternative non-medical methods such as music therapy. After your surgery you should anticipate some pain. To help us minimize your pain (so you can get up and MOVE), we will ask you to rate the intensity of your pain through the use of a pain scale from 0-10 (0 is no pain, 10 is the most excruciating pain you have ever felt).

Understand that a pain goal of 0 is not realistic but a score between 3-5 is an attainable and acceptable score for most patients. It is critical to stay ahead of your pain. We will work closely with you to manage your pain. When your pain is controlled, you recover faster (and WALK more). Careful pain management will allow you to eat, sleep, move, do your therapy, and begin doing normal activities. Management of your post-surgical pain is a high-priority. Don't be afraid to ask for pain medication when you need it.

Cold Therapy

The application of ice to your surgical site is instrumental to your healing process. Ice therapy helps decrease bleeding, swelling and pain. Your surgeon may order ice application following your surgery, which may consist of ice packs or an ice machine. Be sure to intermittently utilize ice therapy, 20 minutes on followed by 20 minutes off. Also, keep a thin barrier between your skin and the cold therapy device. It can also be helpful to intermittently apply an ice pack to the back of your knee, if you do not have an ice machine that covers this area.

Coughing and Deep Breathing

You will be encouraged to take deep breaths and cough after your surgery 8-10 times an hour while awake. Deep breathing while walking and during therapy is also good for your lungs, as this will help keep secretions in your lungs from accumulating. When fluids accumulate it can lead to pneumonia. Your doctor may order an Incentive Spirometer device to assist you with your deep breathing exercises. If this has been ordered for you, you will receive instruction on it. You should continue to use it in the post-surgical period.

Alpenglow Academy |Your Stay at Alpenglow, Page B3

Constipation

Constipation often occurs with pain medication, anesthesia and/or a decrease in activity. Moving (WALKING) as much as possible, staying hydrated and eating plenty of fiber can all be helpful in preventing constipation. If you have a history of trouble with constipation please let your nurse know. Prevention is always more pleasant than the treatment of constipation. You should take stool softeners while taking narcotics. You can use over-the-counter methods and drink prune juice. If you do not have a bowel movement by the second or third day, you may need a laxative, suppository, or enema to relieve your constipation.

Discharge

Your stay in Alpenglow will likely be within 24 to 48 hours, depending on the plan created for you by your surgeon. It is very important to have someone present for the review of discharge instructions. You will also need to have someone available to drive you home. You are not allowed to drive while taking narcotics.

The need for continued outpatient physical therapy will be discussed prior to your discharge home. Ongoing need for therapy after discharge will be discussed with your clinic team at your post-operative appointments.

C: Post-Op Activities:

Physical Therapy, Daily Life & Exercises

Post-Op Activities:

Physical Therapy, Daily Life & Exercises

What to Expect Following Hip Surgery ................................................................ C1 Post-Op Therapy Progression .............................................................................. C2 Therapy Do's & Don'ts........................................................................................ C3 Daily Life Activities

Lower Body Dressing ..................................................................................... C4 Getting Around Post-Op

Toilet Transfers ......................................................................................... C6 Chair Transfers.......................................................................................... C7 Car Transfers............................................................................................. C8 Bed Transfer ........................................................................................... C10 Bed Positioning ............................................................................................ C12 Bathing Following Surgery ........................................................................... C13 Using Walkers

Safety Tips for Using a Wheeled Walker....................................................15 Walking Method (Front-wheeled Walkers).............................................. C16 Managing Curbs ..................................................................................... C17 Using Crutches

Sitting Down & Standing Up................................................................... C18 Walking.................................................................................................. C19 Maneuvering On Stairs ........................................................................... C20 Your Therapy and Home Exercise Program & Other Handouts.......................... C21 Alpenglow Academy | Post-Op

• DON'T pull up on a walker when trying to stand.

Alpenglow Academy | Post-Op Activities, Page C4

Daily Life Activities

Lower Body Dressing After Surgery

The use of a reacher, long-handled shoehorn and sock aid will help you get your lower body dressed without breaking any precautions you may have.

Gather your underwear, pants, socks and shoes, reacher, long-handled shoehorn, sock aid, and walker or other assistive device. Place everything within easy reach. Choose clothes that fit loosely. Put on your socks, pants, and shoes before you stand to pull clothing over your hips.

Wear rubber soled slip-on shoes or use elastic shoelaces.

TIP: It is easiest to have your pants pulled above your knees before you stand to avoid a fall (putting you at risk for breaking your hip) or having to sit back down! And remember if you have a weight-bearing precaution, when you go to stand to pull up or adjust your clothing, put only as much weight as your doctor allows on your surgical leg.

Putting clothes on:

Note: Your therapist may show you different ways to get in and out of bed, depending on your situation. Follow the instructions you are given.

Alpenglow Academy | Post-Op Activities, Page C12

Bed Positioning Following Surgery

Use pillows to keep you comfortable — and to keep your legs apart.

Top-down view — using a pillow to

keep your knees apart:

When resting on your side, use a large

pillow to keep your legs apart and

do not bend your knees or hips.

Do not cross your legs.

Alpenglow Academy | Post-Op Activities, Page C13

Bathing Following Surgery

Before you shower or bathe, be sure you have everything you will need — shampoo, soap, sponge, long-handled brush, and towel — within reach. You may also want a bathrobe or your clean clothes nearby.

Some people will require assistance for transfers and/or bathing following their surgery.

Don't be afraid to ask for help!

Have non-skid bath mats in place for safety. Properly installed grab bars can also be useful. A tub seat/shower chair and hand-held shower head may also be helpful. Do NOT lower yourself to sit in the base of the tub. See your post-operative instructions for water immersion precautions.

Getting into a shower stall with chair facing shower controls: 1. Using your walker, cane, or crutches for support, walk to the edge of the shower stall, then turn so your back is to the stall. DO NOT step into the shower stall.

2. Place one hand on the shower chair backrest, keep your weaker leg slightly in front of you, and leave your other hand on the walker, cane, or crutches (see picture below).

3. Use your hands and stronger leg to lower yourself onto the shower chair, then set your walker, cane, or crutches safely nearby.

4. Scoot back so you're firmly on the chair.

5. Lift your legs over the edge of the shower stall as you turn to sit facing the shower controls.

6. Shower and then dry off while still seated. If you have a robe or clean clothes nearby, you may prefer to get dressed right here.

Getting out of a shower stall:

1. While seated, turn your body and legs to face the opening of the shower stall.

2. Scoot forward on shower chair, keeping your weaker leg slightly in front of you.

3. Bend your stronger leg and stand, pushing off the back of the shower chair to help.

4. Once you have your balance, reach for your walker, cane, or crutches and carefully step out of/ away from the shower stall.

Alpenglow Academy | Post-Op Activities, Page C14

Getting into a bathtub with tub seat facing the faucet: 1. Using your walker, cane, or crutches for support, walk to the side of the tub, then turn so feel the tub on the back of your legs. DO NOT step into the tub.

2. Place one hand on the tub seat backrest, keep your weaker leg slightly in front of you, and leave your other hand on the walker, cane, or crutches (see picture below).

3. Use your hands and stronger leg to slowly lower yourself onto the seat, then let go of your walker, cane, or crutches.

4. Scoot back so you're firmly on the seat.

5. Lift your legs over the edge of the tub one at a time as you turn to sit facing the faucet.

6. Wash (a special hand-held shower hose attachment for your faucet can make this easier) and then dry off while still seated. If you have a robe or clean clothes nearby, you may prefer to get dressed right here.

Getting out of the tub seat:

1. While seated, turn toward edge of tub and lift your legs over the side one at a time.

2. Scoot forward on tub seat if possible, keeping your weaker leg slightly in front of you.

3. Bend your stronger leg and stand, pushing off the back of the tub seat to help.

4. Once you have your balance, reach for your walker, cane, or crutches and carefully walk away from the bathtub.

Note: Your therapist may show you different ways to get in and out of the shower or tub depending on your situation. Follow the instructions you are given.

Alpenglow Academy | Post-Op Activities, Page C15

Using Walkers

Tips for walking, negotiating curbs and stairs, and being safe.

Safety Tips for Using a Wheeled Walker

• Do not take a step unless all 4 legs/wheels of the walker are on the ground.

• Do not push the wheeled walker too far ahead of you. Keep the walker's back legs at least even with your toes.

• Always keep part of your body (at least your toes) inside the frame of the walker.

• Do not lean forward over your walker. Work at maintaining good posture.

• To get up from sitting, do not pull up on your wheeled walker. Instead, push up from your seat.

• To turn or change direction you may need to lift your wheeled walker slightly. Make sure all legs/wheels are firmly on the ground before starting to walk again.

• Be careful when you walk from a tile or hardwood floor to a carpeted floor, or into/out of an elevator. You may need to lift your wheeled walker at the threshold.

• Do not use your wheeled walker on stairs or an escalator.

• Check the tips on the back legs of your wheeled walker often. Replace the tips when they become worn. You can buy new tips from a drugstore or medical supply store.

• Use sliders on the back legs of a wheeled walker to reduce wear on your floors.

STAIRS: Safety Tips for Negotiating Stairs

• Be careful when you walk on wet or uneven surfaces.

• Maintain good posture when walking.

• Do not take a step unless all 4 legs of the walker are firmly on the curb or ground.

• Carry items in a backpack, walker bag, or basket.

• Wear shoes that fit well, support your feet, and are comfortable.

• If you cannot bear weight through a leg, keep it straight out in front of you when maneuvering the curb. This will take practice to do well, but your therapist will help!

Note: Your therapist may show you different ways to move safely, depending on your situation or environment.

Alpenglow Academy | Post-Op Activities, Page C16

Walking (Front-wheeled Walkers)

1. Stand in the middle of the wheeled walker

and grasp the wheeled walker handgrips with

your hands.

2. Push the walker forward an arm's length that

feels comfortable. (The back legs of the

walker should be even with your toes.)

3. Step forward with your affected (weaker) leg

into the middle of the wheeled walker. (See

the white footprint in the diagram at right.)

Continue to grasp the walker grips with your

hands.

Decreasing Your Risk for Blood Clots

Surgery may slow down blood circulation to your legs resulting in the formation of blood clots in the veins of your legs. A blood clot in your leg can develop into a blood clot in your lungs, called a pulmonary embolus (PE). You can help prevent blood clots by WALKING, wearing prescribed equipment (i.e., support hose or sequential compression devices), exercising as specified by your surgeon or physical therapy, and taking blood thinning medication if prescribed by your surgeon. Watch for these signs and symptoms and call your surgeon if you have them:

• Swelling in thigh, calf or ankle that does not go away with elevation.

• Pain/tenderness in calf.

• Unusual warmth.

• Redness or discolored skin to the area of concern.

Call 911 if you notice the following signs of a possible Pulmonary Embolism (PE): • Difficulty breathing

• Chest pain

• Coughing up blood

Decreasing Your Risk for Infection

The most efficient way to decrease your risk for infection is proper hand hygiene. When doing dressing changes, be sure to inspect the incision for signs of infection as mentioned earlier. It is very important to keep your dressings clean and dry. Notify your surgeon if you observe signs of infection such as:

• Fever above 101.00 F.

• Uncontrolled shaking or chills.

• Increased redness, heat, drainage or swelling in or around the incision.

• Increased pain not relieved with pain medications.

An infection elsewhere in your body could cause an infection to your new joint. If you are treated for any type of infection, you should notify your surgeon. If you are experiencing symptoms of a bladder infection (frequent urination, pain or burning with urination, or cloudy urine), contact your primary care physician for treatment and inform them of your recent total joint replacement.

E: Resources

Alpenglow Academy | Resources, Page E1

Frequently Asked Questions

About Total Hip Surgery

We are honored you have chosen Orthopedic Physicians Alaska for your care. Patients have many questions about total hip replacements. Below you will find a list of frequently asked questions with answers. If there are any other questions that you need answered, please contact your surgeon.

What is a Total Hip Replacement?

A total hip replacement is called a total hip arthroplasty or THA for short. In a THA, the damaged bone and cartilage is removed and replaced with prosthetic components.

See a 3-D animation of a hip replacement at opalaska.com/3d-animation Click on "Hip" and scroll down to "Total Hip Replacement"

Will there be a difference in length of my legs after surgery?

Sometimes after your hip replacement surgery one leg may feel longer or shorter than the other. Your surgeon will make every effort in surgery to make your leg lengths equal.

Orthopedic Physicians Alaska

Visit OPAlaska.com for a wealth of information. Here are a few specific links of interest: opalaska.com/hip-leg

This is the OPA website with helpful information regarding what is done during surgery.

This page also gives information on our hip treatment specialists.

opalaska.com/deep-dives

(Click on "Explore the Hip" for 3D interactive imagery, explanations of various conditions and actual surgery images and videos in the "Media Browser."

opalaska.com/3d-animation

See a 3-D animation of a knee replacement surgery; click on "Hip" and scroll down to "Total Hip Replacement."

Alpenglow Academy | Resources, Page E4

About the

American Joint Replacement Registry

Quality Improvement Project

Alpine Surgery Center and OrthoAlaska (OPA) are proud to participate in the American Joint Registry Quality Improvement Project — a nationwide database of implants and other aspects of hip and knee joint replacement.

PURPOSE OF THE PROJECT: To improve the quality of care for patients around the nation who have had a hip or knee replacement. The data may also be used for future research studies related to surgical techniques and devices for patients who have had hip or knee replacement.

INFORMATION SHARED: The information to be shared includes: • Where your surgery took place (Alpine Surgery Center).

• Surgeon name.

• Specific type of implant you received.

• Side and part of your body on which you were operated.

• Your age and other selected medical information that might have impact on the results of your surgery, such as diabetes or heart disease.

• Your social security number, which is fully encrypted and secure in transit and at rest making it impossible for anyone to make out the number.

WHAT ARE THE RISKS? There are no known risks associated with this project. AJRR protects all information in the database by storing it on dedicated servers that have physical and electronic protections verifying that all communications with the registry are from valid sources. In order to track information about your hip or knee surgery, Alpine Surgery Center and the AJRR create a patient identification number that is linked to your social security number. Your information is used for research purposes; the only reason to connect your information back to you would be if some problem were to be discovered by the database.

WHAT ARE THE BENEFITS? You may not receive a direct benefit if you participate.

However, AJRR has alerted hospitals and surgery centers in the past that some of their patients have an implant that is underperforming. Registries like AJRR in other countries help your surgeon select the best implants for you. This information helps us to help you.

Additionally, people who will have joint replacement in the future may benefit from the information obtained in this QI project.

----LYNp4Wn4;LBTYeo Camp Longleaf Counselor Teacher/Professor Recommendation Form Applicant's Name: ________________________________ Date: __________________ Dear Teacher/Professor, The applicant above has applied to work as a counselor at our summer camp, Camp Longleaf. They have listed you as a reference. Please take a few moments to complete this form with the above listed student in mind. Thank you for taking the time to help us get to know your student! Reference Name and school: _____________________________________________________________ Reference Email: ______________________________________________________________________ Grade and Subject of classes applicant had of yours: __________________________________________ Please rate the applicant's personal attributes on a scale of 1 to 5, with 1 meaning "needs work" and 5 meaning "exceeds expectations" Maturity 1 2 3 4 5 Responsibility 1 2 3 4 5 Attitude 1 2 3 4 5 Following Directions 1 2 3 4 5 Teamwork 1 2 3 4 5 Leadership 1 2 3 4 5 Confidence 1 2 3 4 5 Desires to grow and learn 1 2 3 4 5 Accepts Criticism 1 2 3 4 5 Punctuality 1 2 3 4 5 What makes this student standout amongst peers? ______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Additional Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ Please Circle One: I (DO) (DO NOT) recommend this teen for the position of camp counselor Reference's Signature: _________________________________________ Date: ___________________ Please send your completed recommendation to campinfo@eowilsoncenter.org by March 31st, 2020 ----IMJafHCZ;BvBlVL Voter Information


----yQ;pphm;feg Dear DUJLSJAx; Registered Company Name: Trading Name: Registration Number: Registration Date: Business Type: (Pty) Ltd CC (Close Corporation) T/A (Sole Proprietor) Partnership Other Specify: VAT Registration Number: Physical Address: Code: Postal Address: Code: Telephone No: ( ) Facsimile No: ( ) Mobile No: Email Address: Approximate M onthly Purchase Amount: Finance Contact: Contact Number: ( ) Email Address: Banking Details: Name of Bank: Branch Code: Account Number: Trade References: Company Telephone Contact Credit Limit 1. ( ) R 2. ( ) R 3. ( ) R ----IIbYyKj8;LCyPJP RUIGdeNVMq.edu YQJSVYCfTC.edu FFofgTZFFt.edu NfFcUuXiJl.edu

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I will be out of the office from Tuesday, February 18 through Friday, February 21. I will have access to email and will reply if necessary. All other emails will be returned on Monday, February 24. Thank you!



--

Services Manager
Recreation
573-874-7202


----LbP2rOqm;cwMEsd

Dear Prospective Ed.D., Higher Education Strand Applicant:
We are very pleased that you are interested in the Higher Education Strand of CCSU's Doctor of
Education (Ed.D.) in Educational Leadership, designed for current higher education professionals
who aspire to leadership positions on college or university campuses. We look forward to receiving
your application.
As you complete your application, keep in mind the following admission criteria:
1. Master's degree from an accredited institution of higher education in a discipline or
professional field that is relevant to the Ed.D. in Educational Leadership.
2. A 3.00 or higher cumulative average (GPA) in all graduate coursework.
3. Two or more letters of reference from leaders in postsecondary education familiar with
your work. Ask your references to use the form on the next page.
4. Résumé that illustrates important work-related experiences with an emphasis on yo ur
work as a leader at postsecondary institutions of higher education.
5. Acceptable scores on the General Test of the Graduate Record Examination (GRE) taken
within five years of your application.
6. A personal statement covering six important topics:
• Career goals
• Intended area of individual specialization
• Reasons for pursuing a doctorate
• Commitment to residency requirements (one three-day weekend in the first spring
semester, one full week each of the first, second, and third summer sessions)
• Commitment to enrolling in two cohort courses each spring and fall semester
• Commitment to summer enrollment during each 8-week summer session
7. If selected as a finalist, a satisfactory interview with the admissions committee.
We accept new students in alternate years only. Applications are due by October 1, 2017.
Admission standards are rigorous, and not everyone who meets our standards wil l be accepted.
Please note that the admission process calls for submission of materials to two locations. The last
page of this packet is a checklist of the various steps. Submit your Graduate Application and $50
application fee online. Transcripts from every college you have attended as an undergraduate and
graduate student should be submitted to Graduate Admissions in 102 Barnard Hall. In addition you
must send the following materials directly to the Ed.D. Program (attention Rouzan Kheranian) in 320
Barnard Hall:
1. Two letters of recommendation from educational leaders. Use the Reference Form (page
2 of this packet).
2. Your personal statement attached to the form on page 3 of this packet.
3. Your résumé.
4. Your GRE scores. When requesting that scores be sent, use GRE reporting code 3143 to
assure that the Ed.D. office receives your scores.
Cordially,
Peter F. Troiano, Ph.D.
Ed.D. Program Direct or, Higher Education Strand

----YN6523Fx;lYGUHA - Hello, everyone. I think there is confusion over the near-homonyms "apologize" (American spelling), "apologise" (British spelling), and "apologies" (universal spelling). It is informal, but grammatically correct to say "Apologies for the delay in responding." This is a truncation of the more formal "Please accept my apologies for the delay in responding." "Apology" (and its plural, "apologies") is a noun, whereas "apologise" or "apologize" (e.g., "I apologize for the delay in responding") is the verb form of the word. Homonyms are, of course, the most confounding part of the English language, and the words apologies/apologize are frequently confused in writing even by native speakers =) ----rxeXIo0y;cxwLlm

Welcome to ???//??\AFMYF//??\????! We're excited to have you on board. My name is ugmyEmBF, and I'll be your onboarding assistant throughout your trial process. I'd love to learn more about your business, and in turn implement a strategy using our software to increase your sales and overall efficiency. Please reach out if you have any questions and I look forward to helping your eCommerce business grow using our software!

If you have any questions during your trial process, we'd be more than happy to help! Simply hover over the question mark icon to reveal a link to schedule a call with us or utilize the live chat feature in the bottom right corner of your dashboard.

Thanks again and we're excited to have you on board!

rmeLEJZF LCJxq
???//??\GTYFY//??\????.

Best Regards,
J

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In the meantime, here's a reference number: 324512435

If your issue can't wait, please call our Support Team on 13 22 58 or our Sales Team on 13 19 17 and we'll be happy to help.

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Hi Kennedy,

Thank you for reaching out. Before we can get a quote to you, there are a couple of questions we need to understand.

Can you please tell me the language you are interested in and the use case?
Which Operating System does it need supported?
Do you need any additional packages/modules or are you interested in our out-of-the-box distribution for those specific languages?
What is the number of instances?
Timeframe for going into production?

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Thank you,
Ernest Pau
Enterprise Solutions Advocate

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Dir: +1364678527 EXT. 556
Tel: +1668721972

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????UWMNt????? Customer Services

----UIksNk3E;GpcqWA

Dear Student,
Pursuant to the Abraham S. Fischler College of Education (FCE) Student Grievance
Procedure, the Grievance Form is for use in filing a grievance when a satisfactory
resolution is not achieved through a formal appeal. Please note that this form and any
supporting documentation must be properly completed, received, and on file in the
Office of Student Judicial Affairs (OSJA) within fifteen (15) days following receipt of
correspondence disclosing the appeal committee's decision, otherwise, the grievance
will no longer be eligible for review. Students are encouraged to submit the Grievance
Form, and any supporting documentation, well in advance of the fifteen (15) day
deadline for submission.
Should you have any questions or need assistance with the completion and/or
submission of a grievance, please contact OSJA at 2401787473 (toll free at 859276
7440, ext. 34241)
Sincerely,
Office of Student Judicial Affairs
Abraham S. Fischler College of Education

----WKrINYVz;ycyILH


Cardinal Station Newburg Center for Primary Care
215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205
Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208
I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components
UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
enclosing several forms and ask that you completely fill each form out.
The first sheet will help us learn more about you; please completely fill out this
form about your family history. The next sheet is titled, "Authorization for the
use and/or Disclosure of Protected Health Information", and you will need to
completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
medical facilities.
Following, please completely fill out the Registration, Social Services & Consent
Form. Next, you will find our Privacy Notice, followed by an acknowledgement that
you have received and understand our Privacy Policies. Finally, the last form is the
Office Acknowledgements and Policies form. Please read carefully and sign
your name at the bottom of the letter.
Please make sure to bring all of these forms with you to your first office visit.
Do not mail them back to the office. Also, please remember to always
bring your picture ID, current insurance cards and your co-payment. If your
health insurance requires you to select a primary care doctor please do so prior to
your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
If the patient is under 18 years of age he or she must be accompanied by an
adult and will need to bring a copy of their current immunization certificate.
Please arrive 15 minutes ahead of your scheduled appointment time so that if
you have questions about these forms or we need more information, we can
address it all prior to your appointment.
We look forward to seeing you!
University of Louisville Physicians
UofL Family and Geriatric Medicine

----RYSagpuy;FcjXGC Dear Secretary, Open-age Adult Football Clubs' Safeguarding Responsibilities Happy New Year and all good wishes to you for 2020. May we all take this opportunity to say a big thank you to you and your colleagues for all the hard work you put in to ensure your club runs effectively and provides football, week in and week out. We wish you an enjoyable rest of 2019-20 season. We are writing to ensure clubs, at all levels of the game, are clear about their specific safeguarding responsibilities in open-age adult football. Affiliated Footballs Safeguarding Children Policy and Procedures is embedded across youth football and there is information, support and guidance for clubs with under 18 teams to help them to provide children and young people with fun, safe and inclusive football. The purpose of this letter is to support open-age adult football clubs to fully understand their safeguarding responsibilities for under 18s, and adults in disability teams. For the avoidance of doubt every open-age adult club is required to safeguard under 18s and where there are adult disability teams to promote safeguarding adults, across every aspect of the club. Please read the sections below and take any actions you need to. Some clubs will already have completed the requirements detailed below; others will be working towards ensuring this applies to all aspects of their club. If you believe you already meet the requirements detailed below please review the safeguards you have in place across all aspects of your open-age adult teams from first team professionals,semiprofessionals and amateurs to disability teams, community ventures and reserve teams for both men and women. It's essential that every child (under 18) is afforded the appropriate safeguards at every level of the game and in every team. Information, guidance, templates and Disclosure and Barring Service FAQs are available via TheFA.com http://www.thefa.com/football-rules-governance/safeguarding Please note clubs playing within the Premier League should continue to comply with the safeguarding regulations as set out and overseen by the Premier League. Clubs playing within the English Football League (EFL) should continue to comply with the safeguarding criteria as set out and overseen by the EFL. • Premier League Clubs should email safeguarding@premierleague.com for further clarification and orsupport • English Football League Clubs should email safeguarding@efl.com for further clarification and orsupport With respect to the rest of the football pyramid, all clubs playing within the leagues below should ensure they are compliant with the steps outlined in Table 1, and where applicable Table 2. Please use the relevant e-mail addresses below for any queries. • NLS Steps 1-4 should email NLS1-4safeguarding@thefa.com for further clarification andor support • Barclays FA Women's Super League and Women's Championship Clubs should email BarclaysFAWSLandFAWC@thefa.com for further clarification and orsupport The relevant parent County FA will provide further communication and support for the leagues listed below and for all grassroots clubs. Clubs in these parts of the football pyramid must ensure they are compliant with the steps outlined in Table 1 and where applicable Table 2. • NLS Steps 5-7 should contact their parent County FA Designated Safeguarding Officer for further clarification and orsupport • Women's Pyramid Tiers 3 to 7 should contact their parent County FA Designated Safeguarding Officer for further clarification and orsupport • Grassroots clubs should contact their local County FA Designated Safeguarding Officer for further clarification and orsupport. Table 1 Clubs with under 18s in open-age adult teams (including disability teams) are required to: 1. Adopt and adhere to Affiliated Footballs Safeguarding Children Policy http://www.thefa.com/football-rules-governance/safeguarding/section-1-footballs-safeguardingframework View section 1: 1.4 Safeguarding Children Policy and Procedures Club Template 2. Identify which teams have 16 and/or 17 year old players 3. Identify the coaches/managers (including assistant coaches/managers) and medics for these teams and list them on The FA's Whole Game System alongside the registered team. This can be done by the club secretary, assistant secretary or if the club has a youth team by the Club Welfare Officer (Youth Teams). 4. Support coaches/managers (including assistant coaches/managers) and medics working with 16 and/or 17 year olds to complete an FA DBS Check http://www.thefa.com/football-rules-governance/safeguarding/section-3-saferrecruitment-and-dbs-checks View section 3: 3.1 Safer recruitment of volunteers 3.5 Eligibility of roles 3.7 DBS FAQs 5. Provide 16 and 17 year old players with safeguarding information http://www.thefa.com/football-rules-governance/safeguarding/section-7-children-andyoung-people-under-18s View section 7: 7.1 Know your rights in football In support of the roll out of the Affiliated Football Safeguarding Adults Policy, clubs with open-age adult disability teams, need to take the following simple steps to safeguard adults. If this applies to any teams in your club, please read on. Table 2 Clubs with open-age adult disability teams are also asked to: 1. Adopt and share with members the Affiliated Football 'Safeguarding Adults Policy' NB 'easy read' versions are available for adults with learning disabilities http://www.thefa.com/football-rules-governance/safeguarding/section-10-safeguardingadults View section 10: 10.5 Safeguarding Adults Policy and Procedures 2. Appoint a Club Welfare Officer (Adult Disability Teams) and upload their name to The FA's Whole Game System http://www.thefa.com/football-rules-governance/safeguarding/section-10-safeguardingadults View section 10: 10.2 Appointing Club and League WelfareOfficers 10.3 Adding a Club Welfare Officer to WGS 3. Encourage volunteers and staff to complete the newly launched free, online FA Safeguarding Adults course http://www.thefa.com/football-rules-governance/safeguarding/section-10-safeguardingadults View: 10.4 How to access online course 4. Identify and list coaches/managers (including assistant coaches/managers) on The FA's Whole Game System alongside the registered team. Please note - The FA is currently considering with the government's Disclosure and Barring Service the circumstances in which DBS Checks may be required for people working with adults (over-18s) in open-age disability football. Further guidance will be provided in due course. Thank you for supporting football to safeguard adults children safe across every level of the game. If you have any questions, please ensure you refer to the relevant contact points detailed on P1-2, for your part of the game. Best wishes for a positive and successful New Year. Sue Ravenlaw Laurence Jones James Kendall Kelly Simmons Head of Safeguarding Head of National League System Director of Football Development Director of Women's ProfessionalGame Cc Designated Safeguarding Officer/Club Welfare Officer ----OqGkHgQz;KXegfY ACILITATING EFFECTIVE STUDENT LEARNING THROUGH TEACHER RESEARCH AND INNOVATION Teachers in Slovenia found a place for learning through photography mostly outside of regular lessons or as a way to increase lesson variety. We shall conclude with the findings from similar researches abroad (Schiller and Tillett 2004; Bijnens and others 2006) which support our findings. The use of camera and ICT influences teaching and learning because the teacher needs to develop some skills along with the pupils and thus the constructivist approach is the only approach possible. Literature and sources Avgerinou, D. M. (2009). Re-Viewing Visual Literacy in the »Baib d'Images« Era. TchTrends. 53, p. 28 –34 Bijnens M., Vanbuel,M., Verstegen, S., Young, C. (2006). Handbook on Digital Video and Audio in Education The VideoAktiv Bogataj, J., idr. (2001). Učni načrt Družba. Ljublajna: MŠZŠ Project (http://www.videoaktiv.org/ 15. 5. 2010) Dolničar, V., Vukčevič, K., Kronegger, L., Vehovar, V. (2002). Digitalni razkorak v Sloveniji. Družboslovne razprave, 18 (40), p. 83-106. Flynt, E. S., Brozo,W. (2010). Visual Literacy and the Content Classroom: A Question of Now, Not When. The Reading Teacher, 63 (6), p.526-528. Košir, M. idr. (2004).Učni načrt:Vzgoja za medije. Ljubljana: MŠZŠ Krnel, D., idr. (2005).Učni načrt Spoznavanje okolja. Ljubljana: MŠZŠ Schiller, J., Tillett, B. (2004). Using digital images with youn children: challenges of integration. Early child Development and care,174 (4), p. 401-414. Tacol T., idr. (2004). Učni nart Likovna vzgoja. Ljubljana: MŠZŠ Umek, M. (2003). A comparison of the effectiveness of drawing maps and reading maps in beginning map teaching. Internationa research in Geographical and. Environmental Education, 12 (1), p. 18-31. Umek, M., Cimeša, D. (2008). Ali učbeniki za družbo spodbujajo sodoben pouk. In: Medved-Udovič, V.,Cotič, M., Cencič, M. (ur.). Sodobne strategije učenja in poučevanja. Koper: Pedagoška fakulteta, p. 225-238. Partnership for 21st Centu ----LzY7mfmt;rdaiaz

Welcome to ???//??\PRSOO//??\????! We're excited to have you on board. My name is ugmyEmBF, and I'll be your onboarding assistant throughout your trial process. I'd love to learn more about your business, and in turn implement a strategy using our software to increase your sales and overall efficiency. Please reach out if you have any questions and I look forward to helping your eCommerce business grow using our software!

If you have any questions during your trial process, we'd be more than happy to help! Simply hover over the question mark icon to reveal a link to schedule a call with us or utilize the live chat feature in the bottom right corner of your dashboard.

Thanks again and we're excited to have you on board!

rmeLEJZF LCJxq
???//??\LUWJI//??\????.

Best Regards,
J

----V9Xr02Gg;jijhhV

Voter Information


----Ed;wtgg;zfj Dear UYaYBdVw; Registered Company Name: Trading Name: Registration Number: Registration Date: Business Type: (Pty) Ltd CC (Close Corporation) T/A (Sole Proprietor) Partnership Other Specify: VAT Registration Number: Physical Address: Code: Postal Address: Code: Telephone No: ( ) Facsimile No: ( ) Mobile No: Email Address: Approximate M onthly Purchase Amount: Finance Contact: Contact Number: ( ) Email Address: Banking Details: Name of Bank: Branch Code: Account Number: Trade References: Company Telephone Contact Credit Limit 1. ( ) R 2. ( ) R 3. ( ) R ----GM1cYclO;UfJgIa HcIMwPEYyf.edu owxXSVbkrs.edu djLhentDhE.edu qKzRPgdHUn.edu

VERIFY YOUR EMAIL ACCOUNT

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If the link above did not work, you can copy and paste the full URL from your mail client into your web browser. The URL should be a single line, if your mail client splits it into multiple lines, copy and paste each line separately.

ADDITIONAL ASSISTANCE

----mH;dtft;xmd
I will be out of the office from Tuesday, February 18 through Friday, February 21. I will have access to email and will reply if necessary. All other emails will be returned on Monday, February 24. Thank you!



--

Services Manager
Recreation
573-874-7202


----NvE6RU1k;PeQERR

Dear Prospective Ed.D., Higher Education Strand Applicant:
We are very pleased that you are interested in the Higher Education Strand of CCSU's Doctor of
Education (Ed.D.) in Educational Leadership, designed for current higher education professionals
who aspire to leadership positions on college or university campuses. We look forward to receiving
your application.
As you complete your application, keep in mind the following admission criteria:
1. Master's degree from an accredited institution of higher education in a discipline or
professional field that is relevant to the Ed.D. in Educational Leadership.
2. A 3.00 or higher cumulative average (GPA) in all graduate coursework.
3. Two or more letters of reference from leaders in postsecondary education familiar with
your work. Ask your references to use the form on the next page.
4. Résumé that illustrates important work-related experiences with an emphasis on yo ur
work as a leader at postsecondary institutions of higher education.
5. Acceptable scores on the General Test of the Graduate Record Examination (GRE) taken
within five years of your application.
6. A personal statement covering six important topics:
• Career goals
• Intended area of individual specialization
• Reasons for pursuing a doctorate
• Commitment to residency requirements (one three-day weekend in the first spring
semester, one full week each of the first, second, and third summer sessions)
• Commitment to enrolling in two cohort courses each spring and fall semester
• Commitment to summer enrollment during each 8-week summer session
7. If selected as a finalist, a satisfactory interview with the admissions committee.
We accept new students in alternate years only. Applications are due by October 1, 2017.
Admission standards are rigorous, and not everyone who meets our standards wil l be accepted.
Please note that the admission process calls for submission of materials to two locations. The last
page of this packet is a checklist of the various steps. Submit your Graduate Application and $50
application fee online. Transcripts from every college you have attended as an undergraduate and
graduate student should be submitted to Graduate Admissions in 102 Barnard Hall. In addition you
must send the following materials directly to the Ed.D. Program (attention Rouzan Kheranian) in 320
Barnard Hall:
1. Two letters of recommendation from educational leaders. Use the Reference Form (page
2 of this packet).
2. Your personal statement attached to the form on page 3 of this packet.
3. Your résumé.
4. Your GRE scores. When requesting that scores be sent, use GRE reporting code 3143 to
assure that the Ed.D. office receives your scores.
Cordially,
Peter F. Troiano, Ph.D.
Ed.D. Program Direct or, Higher Education Strand

----ixiWTX83;lJdThy - Hello, everyone. I think there is confusion over the near-homonyms "apologize" (American spelling), "apologise" (British spelling), and "apologies" (universal spelling). It is informal, but grammatically correct to say "Apologies for the delay in responding." This is a truncation of the more formal "Please accept my apologies for the delay in responding." "Apology" (and its plural, "apologies") is a noun, whereas "apologise" or "apologize" (e.g., "I apologize for the delay in responding") is the verb form of the word. Homonyms are, of course, the most confounding part of the English language, and the words apologies/apologize are frequently confused in writing even by native speakers =) ----Pn1h2bCP;QTXfUk hMaVueUTOO.edu nryUhNWqPe.edu MFWILuAWix.edu xjXKUQhlof.edu fKxqEVDMzp.edu THQMWWLKeO.edu NacKvYkcfG.edu qBqTaiobRJ.edu xpKRpEYCjD.edu qQQzGvVreU.edu wwKxoGAyRu.edu VEAIRRUVQK.edu adYwSHoUgB.edu EwbCFdWDoj.edu AniFdTfJLc.edu XSjVrtmwwK.edu CKdgaEUghd.edu bYmCeXwqxH.edu FTrIVQcJoL.edu nstfsKUnyJ.edu rVbslrpEUQ.edu tfsXzIVPYE.edu AZuJVTTzgg.edu vhDlQZXvqN.edu naVjBJGaqB.edu CTzFUXwZyd.edu mKdFpzpVaW.edu HvrHwRkYfb.edu BJezTmCrqj.edu qxujYgCdsO.edu ueJpSKMTqG.edu RaLiDtWGym.edu VkpxDtXDRL.edu bkDNOhrwaq.edu WwYFuxtyuF.edu UVAUKNapHp.edu zyTeavlrsi.edu fHaUOzzUDr.edu MBqVeMpbBS.edu AvJKkRCPyT.edu QcQCoEHLDW.edu cEOSaZkjLI.edu ZxlSQAvWiX.edu dHGJoswtfr.edu CvmVMlBEDp.edu jTAvveRjfb.edu EXdYrzreCb.edu qCBNLpCEYV.edu UuGhZvZBIg.edu vFqfXIhhrr.edu UQtrjouvJS.edu YMmXgatUDL.edu FNYjDOekaC.edu CsFyfDhsBv.edu pNByQvIzfl.edu InaXqWxHRy.edu bjkulhJugH.edu rWNaGgnrrC.edu xYaiKvMUlH.edu bzRKffPKLu.edu UoBozJAJkx.edu NnaYAsTzEL.edu NsdWwVSYVb.edu qPZepgrjdh.edu CYWjWxsAHk.edu iWZaCDYmJm.edu tNsHtNrjhd.edu zaRXumxTRO.edu ZvUDFZvnax.edu QyHQSSOWns.edu VGoHwPQVla.edu ogyqjIVYIk.edu ELDReALoZy.edu cbevFMNRQU.edu PDIDujBQHx.edu FETgTYVBrN.edu PBWSxpKYvd.edu jbUeuPFnvL.edu feBwKBDyYn.edu DZXJqslJTE.edu ----gUsQYxHO;LYkQpn Dear Parent / Guardian: The Kirksville Youth Football program for 5th and 6th grade football invites your child to participate in youth tackle football this upcoming fall. The program is open to all 5th and 6th grade boys and girls in the Kirksville area. The program is beginning registration now in order to insure proper planning can be done during the summer months to provide all participants the best experience possible. Our program is evolving and the focus is to make sure kids have all the tools and resources needed to help them enjoy the game of football this year and many years in the future. Our goal is help your child learn the proper basic skills and fundamentals of football, in a controlled environment. We will focus on making the season a fun learning experience. This year, we are offering an early registration discount. The registration form and payment must be turned in by one of the dates listed below. Physicals may be turned in later, but MUST be submitted before practices begin. Players will NOT be allowed to participate without a physical. You may use the Physical form included with the registration form or use a physical form from the school's website. All forms and money returned by: May 31st the fee is $50, between May 31st and July 3rd the fee is $70, after July 3rd the fee will be $90 Forms and fees can be returned to the office at Ray Miller Elementary or mailed to: KV Youth Football, 1515 Green Street, Kirksville, Mo. 63501. Forms MUST be mailed if school year is over. Ray Miller will not take walk‐ in registrations after May 20th. Once you have signed up, your contact information will be entered into our system and added to the email list. You will receive regular updates and information this way. Practices will start approximately the middle of August with games beginning just after Labor Day. Practice times will be 5:30 – 7:00ish three days/week (we will go just two days/week after the first few weeks of practices). Practice days are still TBD. We like to utilize the "turf" field for practices whenever we can, so those days will be determined by availability based on other sports programs. The Kirksville youth football program will host informational meetings and/or clinic later this summer (August) to answer more specific questions about the program and discuss plans for the year. Coach Schottel and the Kirksville Tigers Football Team will be hosting a Youth Football Camp July 18‐20. More information will follow. All 1st‐6th Grade students interested in football are encouraged to participate. The youth football program is a non‐profit, parent run organization. All the equipment needed, is provided, with the exception of a mouthpiece and cleats. The fee is used to pay for costs associated with the program, such as equipment upgrades, helmet upgrades and re‐conditioning, jerseys, shoulder pads, replacing un‐ returned items, and first aid equipment. Coaches are volunteers and are not compensated by the program. For questions or registration forms, contact: Shayne Thomas,kirksvilleyouthfootball@kirksville.k12.mo.us or (660) 234 – 4502. Kirksville Youth Football Registration Complete the following sections, including the Physicians Report for Participation on the back of this form. The Physicians Report for Participation must be completed prior to the player's participation in the program. Part I – General Information Participant's Name Birthdate Name(s) of Grade in Fall of 2016 Parent/Guardian School Attending Mailing Address Shirt Size (e.g. AM, YM) Email ________________ Primary Phone Alternate Phone Part II – Waiver of Liability The undersigned parent(s)/guardian(s) of the above named minor child understands and acknowledges that the Kirksville Youth Football Program is not a program of the Kirksville R-III School District and hereby expressively waive any and all liability as to the Kirksville R-III School District or anyone else should the above named child receive any injury as a result of participation in the Youth Football Program. We/I as understand and acknowledge that participating in an athletic event such as football; we/I assume the risk and responsibility for any injury that might occur. Signature of Parents/Guardian: Part III – Parental Consent Participant's health history information below MUST be completed by PARENT or GUARDIAN. yes no yes no Head Injury History of heart disease, murmur or problems Fainting Recent of frequent bone/joint injury Shortness of Breath Any chronic lung condition Easy Fatigue Diabetes or diabetic Asthma Date of last tetanus booster Additional pertinent information: ____________________________________________________________ ________________________________________________________________________________________ The undersigned parent(s)/guardian(s) of the above named minor child hereby give consent to play Kirksville Youth Football. We/I also give consent for him/her to accompany the team as a member on its out-of-town trips and will not hold the league or program responsible in case of accident or injury whether it be in route to or from another school or during practice or a football game. We/I fully understand that injuries can occur during football participation. If we/I cannot be reached an in the event of an emergency, we/I also give consent and authorize the league/program to obtain through a physician or hospital of its choice such medical care as reasonably necessary for the welfare of the participant, if he/she is injured in the course of football activities. We/I fully understand he/she will not be permitted to complete until verification that he/she has basic accident insurance coverage. My minor child is covered by basic accident insurance. Yes ____ No ____ (Please check) Signature of Parents/Guardian: Part IV – Parent Volunteer Statement During home games, parents will be asked to work the gate and/or to help at the concession stand. Parents of 5th grade players volunteer during the 6th grade game and 6th grade parents work during the 5th grade game. Schedules/Sign-up sheets will be emailed later as the first home game approaches. This is a Parent/Volunteer ran program. We are able to provide all of the equipment, facilities, etc because of this fact. You will only be asked to work one time slot, but other times are more than welcomed. Please sign up as that schedule becomes available later. Part V – Registration Fee - $50 due by 5/31/16; $70 due by 6/1/2016 – 7/3/2016; $90 thereafter Check # _____ or Cash ______ Signature of Youth Football Official ________________________________ Make checks payable to Kirksville Youth Football, 1515 Green Street, Kirksville, MO 63501 Part VI – Physicians Report of Participation Participants Name: ________________________________________________________________________ Pulse __________ Rhythm ___________ B.P. ___________ Height ___________ Weight ___________ Eyes __________ Describe any abnormality ___________________________________________________ Lungs __________ Describe any abnormality __________________________________________________ Heart (any abnormality should be diagnosed by examining physician before qualifying participant) Abnormality: NO ________ YES __________ If yes describe __________________________________ Hernia NO ________ YES __________ Extremities and Back: Please indicate any history or orthopedic defect(s) _____________________________________________ Urinalysis (if indicated) __________________ Blood Count (if indicated) __________________ Additional pertinent information: _____________________________________________________________ I certify that I have completed the above evaluation and _______________ recommend the participant as (DO) (DO NOT) being physically able to compete in the Kirksville Youth Football Program. Date of Examination _________________ Signed______________________________________ Examining Physician (M.D., D.O.)

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