Form Dcf F Cfs2379 E PDF Details

Dominion Energy Carolinas, LLC, (Dominion) has filed a Form Dcf F Cfs2379 E with the Securities and Exchange Commission (SEC). The filing is available for public viewing on the SEC website. According to the form, Dominion plans to offer $2.00 billion in senior unsecured notes due 2029. Proceeds from the sale of the notes will be used to repay outstanding commercial paper, general corporate purposes and other unspecified Dynasty Trust transactions. J.P. Morgan Securities LLC will act as sole bookrunner and Mizuho Securities USA Inc., Wells Fargo Securities LLC, Goldman Sachs & Co. LLC and MUFG Securities Americas Inc. will act as co-managers for the offering. This is a huge accomplishment for Dominion as they continue to grow their business! Offering Details: Issuer: Dominion Energy Carolinas, LLC Date: 1/15/2019 Amount: $2B Description: Senior Unsecured Notes due 2029 Use of Proceeds: Repayment of Outstanding Commercial Paper, General Corporate Purposes, Other Unspecified Dyn

QuestionAnswer
Form NameForm Dcf F Cfs2379 E
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDCF-F-CFS2379-E, examinations, precludes, dcf form print

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DEPARTMENT OF CHILDREN AND FAMILIES

Division of Safety and Permanence

MEDICAL SERVICES CONSENT – CHILD WELFARE FACILITIES

Use of form: Use of this form is voluntary. However, completion will help ensure compliance with DCF 52 and 57 of the Wisconsin Administrative Code. Personally identifiable information gathered on this form will be used for identification purposes only. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Instructions: The authorization is to be completed by the parent or guardian of the child in care and shall be valid for the duration of that child’s placement. If additional space is required, attach separate sheet(s).

A.Facility Information

Name – Facility

Telephone Number – Facility

Address – Facility (Street, City, State, Zip Code)

B.Child Information

Name – Child (Last, First, MI)

Birthdate (mm/dd/yyyy)

Home Address – Child (Street, City, State, Zip Code)

C.Parent / Guardian / Legal Custodian Information

1. Name – Parent / Guardian / Legal Custodian

Address – Home (Street, City, State, Zip Code)

Telephone Number – Home

 

 

Address – Work (Street, City, State, Zip Code)

Telephone Number – Work

 

 

Address – Other

Telephone Number – Other

 

 

2.Name – Parent / Guardian / Legal Custodian

Address – Home (Street, City, State, Zip Code)

Telephone Number – Home

 

 

Address – Work (Street, City, State, Zip Code)

Telephone Number – Work

 

 

Address – Other

Telephone Number – Other

 

 

D. Routine Medical Services Consent and Exclusions

For purposes of routine medical services for the above-named child, I hereby give my consent for the above-named facility to approve the provision of routine medical services including medical and dental examinations and non-emergency prescribed treatments (e.g., tooth repair, immunizations, medications, reproductive health needs assessment). Note: Any medical examination or service provided shall be provided only by an individual licensed to perform the examination or service. Add any exceptions you may have to this provision in the space provided below.

DCF-F-CFS2379-E (R. 04/2010)

E. Emergency Medical Services Consent and Exclusions

In case of a medical emergency involving the above-named child, I understand that the following procedures will be used. I hereby give my consent for the facility to arrange for emergency medical services using the following procedures:

1.A reasonable effort will be made to contact me and secure my consent for needed medical services, including surgical procedures.

2.Verbal consent may be obtained in an emergency situation where time or distance precludes obtaining written consent. It shall be documented in the child’s record by indicating who obtained the consent, who gave the consent and that person’s relationship to the child, and what specific services are authorized by the consent. Verbal consent is valid for 10 calendar days, during which time there shall be a good faith effort to obtain written consent.

3.If I cannot be located within a reasonable time, the facility has the authority to consent to emergency medical services including surgery.

4.The juvenile court has the authority to consent to other medical services.

Note: Any medical examination or service provided shall be provided only by an individual licensed to perform the examination or service.

F. Signatures

Parent / Guardian / Legal Custodian

Date Signed

(Required for all residents under 18 years of age and any residents 18 years of age or older who have been deemed incompetent by a court.)

Resident

Date Signed

(Between 14 and 18 years of age – whenever feasible.)

Resident

Date Signed

(18 years of age or older – Required unless resident has been deemed incompetent by a court.)

2

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