International Students & Programs Office International Center, 9500 Gilman Drive, Mail Code #0018 F-1 STUDENT: STEM EXTENSION OPTIONAL PRACTICAL TRAINING (OPT) REQUEST FORM DIRECTIONS: Student must complete Section #1, #2, and #3A. Employer must complete Section #3B. A complete application will include: □ STEM Extension OPT Request Form □ Copy of I-94 card (fro
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Redandwhitespa.comFACIAL GUEST CARE FORM
PROMISE TO YOU
If you’re not happy with our service for any reason we will reschedule a second visit at no charge or issue a full refund along with our sincerest apologies! PERSONAL INFO
Client Name: ______________________________Therapist: _______________________________
Client Address: _____________________________City:________________ State:_____Zip: ______ Cell Phone: ________________________________E-mail:_________________________________ Birthday: Month_____________ Day______ Anniversary: Month___________ Day_______
Do you have any health concerns your therapist should know about?____________________________ Are you pregnant?_________________________________________________________________ Do you have any allergies or sensitivities to products?_______________________________________ Do you have any special concerns pertaining to your face or body? S Yes S No If yes please specify? ______________________________________________________________________________ Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? S Yes S No Do you use Acutane, Retin A, Renova, Adapalene or any other prescription skin products? S Yes S No Are you currently using any products that contain the following ingredients?S glycolic acid S lactic acid S any hydroxy acid product S vitamin A derivatives (i.e. retinol) S any exfoliating scrubs Do you consider your skin to be sensitive? S Very S Somewhat S Not usual y It’s always a good idea to use the restroom before the service!
Please be advised that a one hour facial session includes: 5 minute initial set up client comfort time, 50 minute actual facial time and 5 minute after session client comfort zone. I hereby consent to the above–mentioned treatment and assume all risk of personal injuries. I voluntarily release Red & White Spa from any and all liability claims, or actions which may be related to any treatments received.
Please ask the Aesthetician within 10 minutes of the start of the facial to STOP if you are not happy with
the service. At that point we will gladly reschedule a second visit or issue a full refund with our sincerest
apologies. However, after 10 minutes we will NOT be able to reschedule or offer a refund.
Client Signature: _____________________________ Date: _____________________________ SPA USE ONLY
Comments / Remarks____________________________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Service Provider Name__________________________________
1. As a general principle, medication shall not be given at school unless it is certified in writing by the attending physician that such medication cannot be administered before or after school hours. 2. Possible exceptions to the general principle: A. Medication for behavior modification (e.g. Ritalin) B. Insect sting allergy—Must have a note from the physician with C. Anticonvulsant medi