Health _ Fitness Center Participant Request Form BP Exploration

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Health _ Fitness Center Participant Request Form BP Exploration Powered By Docstoc
					                             Health & Fitness Center Participant Request Form
                                          BP Exploration, Alaska
                                                (Required fields marked with *)
                               __________________________________
Part 1: Participant Information__________________________________
Participant S        n f        llo g
             tatus (o e o the fo win is required):

 BP Employee:       Self       p use/ mesticp er
                              S o do         artn              BP Retiree:        Self   S o do         artn
                                                                                          p use/ mesticp er

 Building assigned Alyeska employee:                           Other:       rth lo e
                                                                          No S p ERT member
    Self      S o do
               p use/ mesticp er
                             artn                                  F time building assigned c n to ten t
                                                                    ull-                     o trac r/ an


  irst ame: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ *Last n
*F n       __________________                            __________________                    :_ _
                                                     ame: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ *M I_ _ _

 D adg r       :_ _ _ _ _ _ _ _ _ _ mp y_ _ _ _ _ _ _               _____
*I (b e o ADL)#_ _ _ _ _ _ _ _ _ _ Co an :_ _ _ _ _ _ _ *Birth Date: _ _ _ _                             M ale      Female

  me ho e: _ _ _ _ _ _ _ _  rk ho e:_ _ _ _ _ _ _ _ _ ax_ _ _ _ _ _ _ _    to :_ _ _ _ _ _ _
Ho P n _ _ _ _ _ _ _ _ _*W o P n _ _ _ _ _ _ _ _ _ F :_ _ _ _ _ _ _ M ail S p _ _ _ _ _ _ _

        _______________________________________________
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ tate _ _  _ _ _ _ *Email _ _ _ _ _ _ _ _ _ _ _ _ _
City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _S _ _ _Zip _ _ _ _        _____________

      en y n t_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ho e_ _ _ _ _ _ _ _ _ _ _ _ _
*Emerg c Co tac _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ *P n _ _ _ _ _ _ _ _ _ _ _ _

      : pou e d s          r              y________________________
Part 2 S s / ome tic partne information onl________________________
Do       artn        ed y  lo er’ en     ac e.
  mesticp er as defin b emp y s b efits p kag

 p n r’ ame**: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S o so s c mp y _ _ _ _ _ _ _ _ _ _ _ _ _ _
S o so s n    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ p n r’ o an : _ _ _ _ _ _ _ _ _ _ _ _ _ _

 p n r’ rk ho e:_ _ _ _ _ p n r’       erv r: _ _ _ _ _ _ _ _ _ _ _ _ up iso s ho e: _ _ _ _ _ _
S o so s wo p n _ _ _ _ _ _S o so s sup iso _ _ _ _ _ _ _ _ _ _ _ _ S erv r’ p n _ _ _ _ _ _ _
    S o so          div
** “ p n r”is the in idual curren emp y b BP o Aly
                                 tly lo ed y  r         r
                                                  eska o is a BPretiree

       : ptional
 Part 3 O                        e     rag d____________________________
                 information (ncou e )____________________________
Information
      al      cn      n o         ies    y ________________________________
M edic alerts, o ditio s, r allerg (if an ): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

 __________________________________________________
___________________________________________________

 __________________________________________________
___________________________________________________

   o p _ _ _ _ _ hy ian s ame_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _P sic ’ p n _ _ _ _ _ _ _
Blo d ty e: _ _ _ _ P sic ’ n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ hy ian s ho e: _ _ _ _ _ _ _


      : u oriz    _______________________________________
Part 4 A th ation________________________________________
                                                                                                p use/ mesticP er o ly
                                                                                              (S o Do         artn n )

  av ead      ee o h r io       ed er       o io
Ih e r and agr t te p ev uslylist t ms and c ndit ns.                         Contract Code
                                                                                                   ec
                                                                                                  S urityUse Only


         r’ n         _____________________________                                   _________
*Requesto s sig ature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date_ _ _ _ _ _ _ _ _ _

                                                               1
                          er   ollowing
             Please rememb the f       :
         x     u
             Yo must b a memb touse the fitn c ter.
                         e          er              ess en
         x   Nog         f y d
                  uests o an kin are allo    wed.
         x     c             r
             Lo kers are fo dayuse o ly  n .
         x   This is anun             ility f o eed           c p    o tac
                           staffed fac . I y u n assistan e, lease c n t the
                        itn
             Health & F ess S ec p ialist Boat 564-       the      ro tio
                                                     5745, Health P mo n
              p ialist M ike at 564-
             S ec                            r    d              @ p o
                                      5746 o sen anemail toakhp b .c m.


For securityuse only:
   eiv y_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _      ______
Rec ed b :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _




                                     2
   Check List –Requirements f Anchorag Health & Fitness Center Access:
Pre-                        or        e
     ‰   Take all signed M ed ical Clearance andAg       Release ofLiab
                                                  reement/                   orms to S
                                                                        ilityf        ecurity
         Front Desk
     ‰                    af                  id   iew
         Fitness Center S etyOrientation v eo –v and know proced      ures
     ‰   Exercise/              af          eo
                   Equipment S e Use Vid -watch
     ‰   Notification to S         or ad e
                          ecurityf b g access to the Health & Fitness Center
     ‰       g               e
         Bad e access chang with S    ecurity



    BPXA Health & Fitness Center -FacilityUse Guidelines & Policies
    The Health & Fitness Center is locatedin the b                      e
                                                  asement ofthe Anchorag head quarters
                                           uild .
                                          b ing
                   acilityis not stafed S
               The f                               oes
                                     f . ecurityd complete walkthroug     hs.
x      urs f c         0       :0 M
     Ho o ac ess:Daily3:0AM –100 P .
x      c
     Ac ess is limited to:
                 lo ees d o do
     x BP emp y an sp use/ mesticp er      artn
                        d o do
     x BPretirees an sp use/ mesticp er artn
     x Building assigned Aly      ip e        lo ees d o do     artn
                            eska P elin emp y an sp use/ mesticp er
     x F time building assigned c n to ten t
         ull-                      o trac r/ an
           rth lo e
     x No S p ERT memb        er
x          n der
     Noo e un 18y         ears o ag is p
                                f e     ermitted. Nov rs o g
                                                      isito r uests are p              latio f
                                                                          ermitted. Vio no these
       o ies                  ss f      riv es.      lato        se c      riv es r erio f
     p lic will lead tolo o user p ileg Vio rs will lo ac ess p ileg fo a p d o 6
         n       r       ffen
     mo ths fo first o se an p     d erman t lo o ac ess fo sec n o se. S uritywill do umen the
                                          en ss f c         r     o d ffen     ec           c    t
       io n          ug      n iden
     v latio thro h anI c t Rep rt (I an remo e the ac ess fro the v lato s b e. S ec
                                        o R) d           v       c      m      io r’ adg p ific
          ip ary tio             e       y     io r’       lo er. f,         d f
     disc lin ac nmayb takenb the v lato s emp y I at the en o the 6 mo ths, v lato       n the io r
                  ib    r c                        itn        ter, he       o lete
     is still elig le fo ac ess tothe BPHealth & F ess Cen s/ must c mp all required fo        rms
        c       g            rien n
     in ludin the safetyo tatio .

x     erso n                   e           itn     ter
     P n el whowish toutiliz the Health & F ess Cen must sig anAg
                                                               n            t d
                                                                     reemen an
              f
     Release o Liab        rm, d e hy ian r hy ian              t n
                   ilityfo an hav a p sic o p sic assistan sig a M edic      al
            c o          th rms    e o leted an sub
     Clearan e F rm. Bo fo must b c mp          d              ec            ro t
                                                     mitted toS urityat the F n Desk
       r adg c          p n rs     n r p uses/ mesticP ers.
     fo b e ac ess. S o so must sig fo S o     Do         artn
x      erso n                     h    itn
     P n el are required towatc the F ess Cen S ter afetyOrien      n d erc
                                                               tatio an Ex ise
           men
     Equip t Orien         n ideo
                      tatio v s. The v       an e hec      ut m ec       . ec
                                        ideoc b c ked o fro S urity S uritywill
         w adg c                       itn      ter n e erific no the Ag
     allo b e ac ess tothe Health & F ess Cen o c v           atio f            t d
                                                                          reemen an
                 ility F ilityUse Guidelin & P lic an M edic Clearan e fo hav b
     Release Liab , ac                    es   o ies d          al      c rms     e een
         n    d      rien    n ideo
     sig ed an the o tatio v s hav b v e een iewed.
x             uld all 2222 torep rt anemerg c ev t o torequest medic assistan e.
     Users sho c x              o          en y en r                al       c

x    Please b aware o y ur surro din s an the lay ut o the fac . P sp ial atten nto
              e       f o       un g d           o f          ility ay ec       tio
        it attern alarm dev es, ex g
     ex p        s,                              d ther safetyequip t. I y u are un
                           ic fire tin uishers an o                 men f o         sure
      f        ac    n ro edures, S urity
     o the ev uatio p c          ask ec   .
x      c        o tro     y ard
     Ac ess is c n lled b c reader. All users must acquire autho atio v anac ess b e
                                                                riz n ia      c     adg
          ter               itn      ter. o terin , g inusin the c mp
     toen the Health & F ess Cen Up nen          g lo -        g                 al
                                                                    o uter termin at the
        C ro t           g o adg D umb r               ase f o p er,
     HF F n Desk usin y ur b e I n er o inthe c o sp use/artn the last 4
        its f c
     dig o so ial sec urityn     er.     w 2            ain g c       r o ame to
                              umb Allo 1- weeks after g in ac ess fo y ur n
       p
     ap ear inthe database.


                                                 3
x     c           o e       n     d      r
    Lo kers will n t b assig ed an are fo dailyuse o ly(un awarded thro h the an ual
                                                    n     less           ug        n
      ited          tio ).  y c          e
    Un W ayauc n An lo ks will b remo ed fro lo kers. P
                                               v      m c             lo    c
                                                               lease c se lo ker after use.
x         rms
    All fo are av  ailab o - e an inhard c p fro the Health & F ess Cen HR (n
                        le n lin d         oy m                itn     ter,  ew
          ac     n ), d ec         n
    hire p kets o ly an S urityfro t desk.
x         c ts, c ts d ear                e   o            erv r d   E ardless
    All ac iden in iden an n misses must b rep rted toa sup iso an HS reg
     f         usn
    o the serio ess.
x     irst           c        o     c      o o                 ato b y d ehin
    F aid kits are lo ated inb th lo ker ro ms, utside the elev r lo b an b d the
         ess n
    fitn fro t desk.
x    ac           ag   t       o sib    r
    F ilities M an emen is resp n le fo all fac       d     men     ten c d c
                                               ilityan equip t main an e an ac ess
     o tro      mp      air/o c
    c n l. Co lete rep c n ernc     ards an tagap ro riate equip t. Rep rt c n ern to
                                           d       p p          men    o oc s
     58 0
    x 0.
x    ro er       c thin
    P p attire, lo gwhic en h sures min           p sure, d c sed to sho must b
                                       imal skinex o     an lo      e   es       e
        rn              k p d o ras          ut o erin s   o o sidered ap ro riate
    wo at all times. Tan to s an jgb witho c v g are n t c n             p p
    attire.
x              f     men
    Time use o equip t will b b         n     ho o stem, with anex ec no
                                e ased o the “ n r sy  ”          p tatio f
     o sideratio fo o
    cn                                g eak erio f     p
                 n r ther users. Durin p p ds o use, lease limit c     v ular
                                                                  ardio asc
         men       e
    equip t usag to30min     utes.
x       g b
    Usin a “ uddysystem”is stro g en o    ed. rkin ut         d           d an
                               n ly c urag W o go with a frien is safer an c
           rko      re    tiv
    make wo uts mo effec e.
x               p ted     o  w    ro erlyuse the equip t b re usin . Be sure tov
                                                      men efo     g
    Users are ex ec tokn w ho top p                                             iew
          erc         men
    the Ex ise Equip t Orien     n ideo
                            tatio v .
x           ers, urlin iro s an o
    Hair dry c                       tric  c ries      e p g
                      g n d ther elec al ac esso must b un lug ed after use.
x     ur rimaryc p v
    Yo p         are ro ider will b ab tosig the M edic Clearan e fo
                                   e le       n        al            f wev o
                                                               c rm. I ho er y u
       o     e rimaryc p v
    don t hav a p                              me p n
                        are ro ider here are so o tio s:
    ƒ    ro iden e sp       c r           e    0     49
        P v c Ho ital Do to Referral Lin –(9 7) 261- 22
    ƒ             io al c r             e   0)   8
        Alaska Reg n Do to Referral Lin –(8 0 265- 624
    ƒ       o     c atio al
        Beac nOc up n Health & S          erv es  r re- erc  reen g n   0
                                    afetyS ic –fo p ex ise sc in o ly–(9 7) 222-
        7612

x              g
    W henusin the c            efo r         rkin ut, lease sto y ur wo ut b o the
                     afeteria b re o after wo go p             re o      rko ag n
            der        s y       afé tran e d o
    shelf un the tray b the c en c an n t inthe hallway P      s. lease en       o
                                                                           sure y u have
     ro er      tific n n        ag
    p p iden atio o the b as well.
x          o ies       jt    han e   ut rio o e
    These p lic are subec toc g witho p r n tic at the c mp y s disc
                                                        o an ’           n
                                                                    retio .




                                             4
Final Check List
    ‰ Hand carryall sig    nedM ed ical Clearance andAg       Release ofLiab
                                                       reement/                  orms to
                                                                            ilityf
        Security
                         af                 id
    ‰ Fitness Center S etyOrientation v eo –watch and know proced     ures
    ‰ Exercise/                af         eo
                  Equipment S e Use Vid -watch
    ‰ Notif  ication to S        or ad e
                         ecurityf b g access to the Health & Fitness Center
            g
    ‰ Bad ingprocess with S     ecurity


       er h saf y egins wit y u.W e ar r o le f ro selv and f roh s t
 Rememb t at et b         h o         e esp nsib o ur es    o t er o
                        e     e, un r o env o
                   ensur a saf f wo k ut ir nment  .



 ec    n
S urityI itial                                                                  p ratio (Alaska) I c
                                                                           BPEx lo     n         n.
                                                                                       O x 6612
                                                                                      P Bo 19
        eiv
Date Rec ed                                                                   c rag AK 9 -
                                                                           An ho e, 9 519 6612
                                                                          ho e: 0
                                                                         P n (9 7) 564-       r
                                                                                        5746 o 5745
     s
Video Viewed




                                              5
                              Agreement and Release of Liability
                                   BPXA Fitness Centers
The un      n     uld           e
      dersig ed wo like toutiliz the BPEx lo
                                         p ratio (Alaska) I c n n staffed fitn c ters an
                                                n         n. o -              ess en    d
  tiv         r
ac ityareas fo the p o o ex ise,
                    urp ses f erc educ n an rec
                                        atio , d reatio . Use o the c ters is a v lun
                                                         n       f      en         o tary
  tiv , dertakenb me fo myo b efit.
ac ity un          y      r    wn en

1.    n o sideratio o g in memb
     I cn             n f ain g            ershipo b gallo
                                                    r ein              artic ate             tiv
                                                               wed top ip inthe ac ities an p g         d ro rams
      f
     o the BPEx lo           n            n.
                    p ratio (Alaska) I c fitn c ters an touse its fac
                                                 ess en        d             ilities,        men an
                                                                                       equip t, d mac ery    hin
                n          ay t f y             r harg I           y       e,
     inadditio tothe p men o an fee o c e, dohereb waiv release an fo er disc e BP        d rev          harg
        p ratio (Alaska) I c Aly
     Ex lo       n                            ip e erv e mp y d
                              n ., eska P elin S ic Co an an its o ers,           ffic direc rs, to shareho    lders,
     sub sidiaries,            ag ts, wn emp y rep
                    affiliates, en o ers, lo ees, resen es,                        n an
                                                                    tativ assig s, d all o                 m y d
                                                                                                  thers fro an an
             o sib          r
     all resp n ilities o liab           r j
                                 ilityfo inuries o damag resultin fro myp ip ninan ac ities
                                                     r      es        g m            artic atio          y tiv
      r           f        men r        hin
     o myuse o equip t o mac eryinthe ab v men n fac                                r
                                                        o e- tio ed ilities o arisin o o my  g ut f
      artic atio          y tiv                  ility do            y
     p ip ninan ac ities at said fac . I alsohereb release all o tho men n an an     f     se      tio ed d y
     o         tin o
      thers ac gup ntheir b                m y         o sib
                                 ehalf fro an resp n ilityo liab r            r y j            r
                                                                      ilityfo an inuryo damag tomy      e       self,
       c      g se aused b the n lig t ac o o
     in ludin tho c             y       eg en t r missio o an o tho men n o o
                                                                n f y f        se       tio ed r thers ac gotin n
     their b        r       y            g ut f r o n ted                artic atio
            ehalf o inan wayarisin o o o c n ec with myp ip ninan ac ities o the BP           y tiv        f
        p ratio (Alaska) I c fitn c ters o the use o an equip t at the BP Ex lo
     Ex lo       n            n.      ess en        r        f y         men                            n
                                                                                               p ratio (Alaska)
      n.      ess en
     I c fitn c ters.

      n         ____
     (I itials _ _ _ _ )

2.    un      d d                      g flex ility an
     I derstan an am aware that stren th, ib , d aero icex ise, c
                                                             b                  g         f
                                                                    erc in ludin the use o equip-
         t,   o tiallyhaz us ac ities. Ialsoun
     men are p ten         ardo     tiv             derstan that fitn ac ities in o e a risk o
                                                           d          ess tiv    v lv         f
       j    d en           d
     inuryan ev death an that Iam v luno tarilyp ip ginthese ac ities an usin equip t
                                                 artic atin              tiv   d    g       men
       d    hin           o     e f
     an mac erywith kn wledg o the dan ers in o ed. Ihereb ag toex resslyassume an ac ep
                                          g      v lv          y ree         p              d c t
       y d            f j     r
     an an all risks o inuryo death.

      n         ____
     (I itials _ _ _ _ )

3.    do       y             lare
     I hereb further dec my tob p sic so d an sufferin fro n c n
                                     self     e hy ally un d                                      n imp
                                                                              g m o o ditio , airmen           t,
             in         , r ther illn that wo p en myp ip ninan o the ac ities an
     disease, firmity o o            ess         uld rev t       artic atio          y f       tiv        d
      ro rams o the BP Ex lo
     p g         f                   n            n.
                             p ratio (Alaska) I c fitn c ters o use o equip t o mac eryex ep
                                                         ess en       r      f       men r        hin       c t
     as herein                        y kn wledg that Ihav b in rmed o the n fo a p sic ’
              after stated. Idohereb ac o            e          e een fo           f     eed r hy ian s
       p v       r      artic atio
     ap ro al fo myp ip ninanex ise/ ess ac ityo inthe use o ex ise equip t an
                                             erc fitn        tiv    r             f erc            men d
         hin .
     mac ery Ialsoac o              e              een o
                          kn wledg that it has b rec mmen that Ihav a y
                                                                 ded                        r    re
                                                                                e earlyo mo frequen         t
      hy al amin nan c n
     p sic ex                               n          hy ian         hy al tiv , erc an
                      atio d o sultatio with a p sic as top sic ac ity ex ise, d use o                      f
       erc      d       in        men
     ex ise an train gequip t sothat Imig hav rec mmen
                                                     ht    e o               n o c in
                                                                        datio s c n ern gthese fitn   ess
       tiv        d       men
     ac ities an equip t use. Iac o     kn wledg that I e either had a p sic ex
                                                   e      hav                                 atio d/r
                                                                              hy al amin nan o hav            e
      een iv        hy ian s ermissio top ip an dohereb assume all resp n ilityfo my
     b g ena p sic ’ p                    n     artic ate, d            y                 o sib        r
      artic atio d tiv            an        atio f        men d
     p ip nan ac ities, d utiliz no equip t an mac eryinmyac ities.      hin             tiv

      n         ___)
     (I itials _ _ _ _
 ec    n
S urityI itial                                                                                    p ratio (Alaska) I c
                                                                                             BPEx lo     n         n.
                                                                                                         O x 6612
                                                                                                        P Bo 19
        eiv
Date Rec ed                                                                                     c rag AK 9 -
                                                                                             An ho e, 9 519 6612
                                                                                            ho e: 0
                                                                                           P n (9 7) 564-       r
                                                                                                          5746 o 5745
     s
Video Viewed




                                                         6
                                     CAL CLEARANCE FORM
                                 M EDI

User Name:                                                       rk
                                                              W o Numb  er:
 pn r        lo ee)
S o so (Emp y Name:                                             me
                                                              Ho Numb   er:
      f
Date o Birth:                                                     lo er f
                                                              Emp y (o emp ylo ee):
     e D :
Badg I #

           al ro ider:
Dear M edic P v

     p ratio (Alaska) I c (BP
BP Ex lo    n          n.            p                lo ee itn ter c
                               XA) o erates an Emp y F ess Cen lo ated in the
  c rag                     g
An ho e Headquarters Buildin . This f                 f .
                                    acilityis not stafed

 rio      g       ility eac
P r tousin the fac , h user must o taina medic c
                                   b                   c
                                              al learan e. BP  XA uses the American
   lleg f p rts       in
Co e o S o M edic e (ACS ) g         es      e ardiacrisk fac rs.
                            M uidelin todefin c              to

No mo iab r f tr are:
  n- dif le isk aco s

             o e               ry an   e
   Heredity(p sitiv familyhisto ), d Ag (M ale > 45, emale > 55)
                                                    F

M o iab f tr are:
   dif le aco s

   c     t ig         kin
    urren c arette smo g                       b
                                              o esity
      p     sio
   hy erten n                                   p c lestero
                                              hy er-ho         lemia
   diabetes                                   seden            le/hy al ac ity
                                                    tarylifesty p sic in tiv

  e      M ec mmends ap r p iat r assessment
Th ACS r o                 p o r e isk       and sc eening p io t ex c inc
                                                   r        r r o er ise            h sic
                                                                          luding a p y ian
   er ised gr
sup v               er ise est o   der e  igh isk
             aded ex c t f rmo at and h r indiv        iduals.

¾ W ith y ur en rsemen o this fo
          o    do     t f       rm,the user will b ab to utiliz the BP
                                                  e le         e          itn
                                                                      XA F ess
  Cen ter(s).

 ____________                    ally leared toutiliz the n n staffed BP F ess
_ _ _ _ _ _ _ _ _ _ _ _ _is medic c                  e     o-           XA itn
   ter r artic ate inBP ex ise p g
Cen o p       ip       XA erc     ro rams wit nor r t ns.
                                              h     esticio

 ____________                    ally leared toutiliz the n n staffed BP F ess
_ _ _ _ _ _ _ _ _ _ _ _ _is medic c                  e     o-           XA itn
   ter r artic ate inBP ex ise p g
Cen o p       ip       XA erc                                         ec
                                  ro rams wit so r r t ns as sp ified here:
                                              h me esticio


 ____________                        ally leared toutiliz the BP F ess Cen o
_ _ _ _ _ _ _ _ _ _ _ _ _is not medic c                  e      XA itn    ter r
p     ip       XA erc    ro rams.
 artic ate inBP ex ise p g


 hy ian
P sic Name:                                               Date:
                     (Prin o stampp )
                          t r      lease
 hy ian ig ature:
P sic S n                                                  ax
                                                          F :

Address:                                                  Phone:




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posted:8/3/2011
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