ࡱ> ,.+  bjbjxx .l,,,,,@@@8x@3" )$q,",,9ZZZR,,ZZZZyRZ03ZJZ,ZD1>o,Z$1111113111111111 : STATEMENTtc \l1 "INSURANCE STATEMENT of INSURANCE COVERAGE Social Work Practicum Print form, complete, and return to your SW 440 instructor by the designated due date. I, , certify that I have paid for Student Health and Print Students Name Major Medical Program provided by 鶹ý Illinois University for students, or have similar coverage for myself through another policy, and will not cancel or change this insurance coverage during the period of my Practicum. I understand the risks involved and that it is binding on my heirs and on University personnel. _______________________________ ______________________________ Student Signature Date     Bachelor of Social Work Program | 鶹ý Illinois University Stmt of Insurance Covrg: 08/16   %&=RSTVW[`sssf\H;hsh[ROJQJ^J&jhsOJQJU^JmHnHuh:OJQJ^Jh[RhrOJQJ^Jh[Rh:OJQJ^Jh[ROJQJ^J h:56CJOJQJ^JaJhshrOJQJ^Jh[Rhr:OJQJ^Jh[Rhs:OJQJ^J$h[Rh[R5>*OJQJ\^J-jh[Rh[R5>*OJQJU\^J!h[Rh[R5>*OJQJ\^J=STUV@ A }h$ 8X 8x!a$gd[R$ X X8x!a$gd[R$ X 8x!a$gds$ X 8x!da$ X 8x!d$ X 8x!da$gds$ X 8x!d@&a$gd[R      ȹȹ|h:h[Rh[RCJ OJQJ]aJ h[Rh:CJ OJQJ]aJ h`>CJ OJQJ]aJ h6jh6UhshrCJOJQJ^JhshrOJQJ^J#hshsCJ H*OJQJ^JaJ h[RCJ H*OJQJ^JaJ h[ROJQJ^JA B C     !$gds !X 8x!d X 8x!d,1h/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH d@d  Heading 1($ X 8x!d@&CJOJQJ^Jj@j  Heading 2.$$ X 8x!d@&a$CJOJQJ^JDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List L@L Header !1$7$8$H$ CJOJQJ4 @4 Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] $ kkkn A   8@(  VB  C D"?B S  ?Xt _Toc497029315%fE3gE3hE3iE3!!)2(1<<9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType  3=RT    `>[R