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13-2014
Supreme C nnsylvania Con leas Cum County The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service of pleadings or other p4pers as required by law or rules of court. Commencement of Action: 13 Complaint 0 Writ of Summons © Petition 0 Transfer from Another Jurisdiction 0 Declaration of Taking Lead Plaintiff's Name: Lead Defendant's Name: Mina Warsame,a Minor West Shore Evangelical Free Church Dollar Amount R uested: within arbitration limits Are money damages requested? ®Yes O No ® (check one} [3outside arbitration limits Is this a Class Action Suit? 0 Yes M No Is this an MDJAppeal? (3 Yes © No Name of Plaintiff/Appellant's Attorney: Ride M.Grams, ID No.203076 0 Check here if you have no attorney tare a Self-Represented fPro Se] Litigant) NNW l Case: Place an"X"to the left of the Q=case category that most accuratbly despribes your MAL Y CASE. If you are making more than one type of claim,check the one that you consider most important. TORT(do not include Mass Tort) CONTRACT(do not include Judgments) CIVIL APPEALS 0 Intentional 0 Buyer Plaintiff Administrative Agencies 0 Malicious Prosecution 0 Debt Collection:Credit Card 0 Board of Assessment 0 Motor Vehicle 0 Debt Collection:Other 0 Board of Elections Nuisance Dept.of Transportation Premises Liability 8 Statutory Appeal:Other 0 Product Liability(does not include 0 mass tart) Employment Dispute: Slander/Libel/Defamation Discrimination Other: 0 Employment Dispute:Other 0 Zoning Board 0 Other: 0 Other: MASS TORT 0 Asbestos 9 Tobacco Toxic Tort-DES Toxic Tort-Implant REAL PROPERTY MISCELLANEOUS 0 Toxic Waste Other: [3 Ejectment (3 Common Law/Statutory Arbitration 8 Eminent Domain/Condemnation 0 Declaratory Judgment Ground Rent Mandamus 0 Landlord/Tenant Dispute 8 Non-Domestic Relations E3 Mortgage Foreclosure:Residential Restraining Order PROFESSIONAL LIABLITY 0 Mortgage Foreclosure:Commercial 0 Quo Warranto 0 Dental 0 Partition 0 Replevin 0 Legal 0 Quiet Title 13 Other: 0 Medical 0 Other: 0 Other Professional: Updated 11112011 d FILED-OFFICE OF THE PROTHONOTARY 2113 APR 15 FM 12: 42 CUMBERLAND PENNSYLVANIA TY Adina Warsame,a Minor,by Ahmed Warsame,Guardian and I.eyla Samriye,Guardian : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA West Shore Evangelical Free Church : '�p� j,f ►g NO. Defendant Civil Term NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE CLAIMS SET FORTH IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN TWENTY (20)DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED, BY ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY AN ATTORNEY AND FILLING IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. YOU ARE WARNED THAT IF YOU FAIL TO DO SO THE CASE MAY PROCEED WITHOUT YOU AND A JUDGEMENT MAY BE ENTERED AGAINST YOU BY THE COURT WITHOUT FURTHER NOTICE FOR ANY MONEY CLAIMED IN THE COMPLAINT OR FOR ANY OTHER CLAIM OR RELIEF REQUESTED BY THE PLAINTIFF. YOU MAY LOSE MONEY OR PEOPERTY OR OTHER RIGHTS IMPORTANT TO YOU. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO THE TELEPHONE OR THE OFFICE SET FORTH BELOW TO FIND WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 1-500-890-8108 717-248-3166 .7S C'4# 59 s� IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY, PENNSYLVANIA ADINA WARSAME,a Minor by Ahmed Warsame, Guardian and Leyla Samriye,Guardian Case No. Plaintiff/Petitioner V. • 3 WEST SHORE EVANGELICAL FREE CHURCH Defendant/Respondent PETITION FOR COURT APPROVAL OF SEIII&WNT OR COMPROMISE OF ACTION INVOLVING.N W40R TO THE HONORABLE,THE JUDGES OF SAID COURT: The Petition of Adina Warsame, a minor, filed by her parents and natural guardians, Ahmed Warsame and Leyla Samriye, by and through their undersigned counsel, respectfully represents that: I. The Plaintiff/Petitioner, Adina Warsame, a minor (the "Plaintiff'), was born on June 2,2004,and her Social Security Number is XXX-XX-5436. 2. Ahmed Warsame and Leyla Samriye, are the parents and natural guardians of the minor Plaintiff. 3. The Plaintiff resides with her father, Ahmed Warsame and her mother, Leyla Samriye, (collectively the"Guardians"), at 1025 Punjab Drive,Essex,Maryland 21221. 4. A guardian was not appointed by the Court for the minor. 5. The Defendant/Respondent (the "Defendant") is West Shore Evangelical Free Church, whose principal place of business at all relevant times was 1435 Williams Grove Road, Mechanicsburg,Pennsylvania 17055. 6. On February 9, 2011, the Plaintiff was a passenger in a van owned by the Defendant, and was thrown from the vehicle as the driver was turning in the parking lot at 1435 r Williams Grove Road, Mechanicsburg, Pennsylvania, the premises of the Defendant, sustaining injuries to her foot,back and knee. A copy of the medical records is attached as Exhibit"A." 7. The Plaintiff was transported to Holy Spirit Hospital by way of ambulance. A copy of the Patient Bill for the transport of the Plaintiff and the Plaintiff's Hospital Bill are attached hereto as Exhibit"B." 8. As a result of the aforementioned injuries,the Plaintiff and her parents and natural guardians incurred costs totaling $8,551.00, which costs are sought to be reimbursed from the settlement. The specific costs are as follows: Dillsburg Ambulance $ 843.00 Holy Spirit Hospital $7708.00 Total $8551.00 9. A settlement has been proposed in the amount of $15,000.00, for Plaintiff, a minor. 10. Attached hereto as Exhibit "C" is a Verified Statement of the minor Plaintiff's father and natural guardian,Ahmed Warsame, certifying the physical and mental condition of the Plaintiff,as well as approval of the proposed settlement and distribution. i 11. Attached hereto as Exhibit "D" is a Verified Statement of the minor Plaintiff's mother and natural guardian, Leyla Samriye, certifying the physical and mental condition of the Plaintiff,as well as approval of the proposed settlement and distribution. 12. Pursuant to Rule 2039 of the Pennsylvania Rules of Civil Procedure, the Guardians hereby present this Petition to this Court for approval. 13. Further, the Guardians hereby request that this Honorable Court approve the payment of counsel fees out of the above referenced settlement proceeds. By way of agreement between Guardians and counsel for the Plaintiff, counsel for the Plaintiff is hereby entitled to $3,750.00 of the above-referenced proposed settlement, an amount equal to twenty-five percent of the proposed settlement amount. Said amount is fair and reasonable. 14. Defendant has agreed to the proposed settlement. A copy of the proposed Parents' Release and Indemnity Agreement is attached hereto as Exhibit"E". WHEREFORE, Plaintiff/Petitioner Adina Warsame, a minor, by her parents and next friends Ahmed Warsame and Leyla Samriye, requests that she be permitted to enter into the settlement recited above and that the Court enter the below Order for Distribution: Court Costs/Filing Fees $ 103.75 To: Adina Warsame $ 11,146.25 Date of Birth: June 2, 2004 Social Security No.: 218-71-5436 Sagal, Cassin Filbert& Quasney,P.A. $3,750.00 TOTAL: $15,000.00 Respectfully submitted, SAGAL,CASSIN,FILBERT&QUASNEY,P.A. Dated: April 11, 2013 ck M. , squire Attorney I. No. 203076 600 Washington Avenue Suite 300 Towson,Maryland 21204 Phone: (410) 823-1881 Fax: (410) 823-8032 Email: r ramsgsagallaw.com VERIFICATION I, Ahmed Warsame, the parent and natural guardian of the minor, Adina Warsame, do hereby verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. § 4904,relating to unsworn falsification to authorities. p ed Warsame VERIFICATION I, Leyla Warsame, the parent and natural guardian of the minor, Adina Warsame, do hereby verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true and correct to the best of my knowledge,information and belief. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. § 4904,relating to unworn falsification to authorities. eyla wAsCme i' IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY, PENNSYLVANIA ADINA WARSAME, a Minor by Ahmed Warsame, Guardian and Leyla Samriye, Guardian Case No. Plaintiff/Petitioner V. WEST SHORE EVANGELICAL FREE CHURCH Defendant/Respondent CERTIFICATE OF SERVICE I, Rick M. Grams, certify on this 11th day of April, 2013 that a true and correct copy of the enclosed Petition for Court Approval of Settlement or Compromise of Action Involving Minor has been served via first class mail,postage prepaid,upon the following: Richard W. Yost Michael F. Kenoschak Yost&Tretta, LLP Two Penn Center Plaza, Suite 610 1500 John F. Kennedy Boulevard Philadelphia,Pennsylvania 19102 Attorneys for Defendant Rick M. GAms �v EXXITr ' PATIENT FACEEET Health sotem c#I tne,P rat 4"4" SuPROVY DATE ST moo. dWW1k436 02/09/11 16:35 su E 1382 ` T 6 06!0212004 2 F S COIIMCTIOiN TO ANY 4011110041MF I»1 OR 02!04/11 17:21 !/ P?JI, WARSAINE .ADINA A P 666 CEMERLAND POINTE CIRCLE CHILD I MECHANICSBURG, PA (it IP 17055 Y 443 - 653-1731 PHOTO N - GE0.0OOE LANGUAGE ENGLISH OC CUPAYM 0 SA14RIYE ,LEYLA MI 0 666 CUMBERLAND POINTE CIRCLE UW UNK i INECHANICSBURG, PA A► Art 17055 Ap a0 443 - 653-1731 T R RELATIONSHIP D I to SAMRIYE ,LEYLA � C 666 CUMBERLAND POINT O EM MECMIAI!iICSBURG, PA M , ,,.. T 17055 _ T RELATIONSHIP M 1c IP rt HOME PHONE 443 - 653-1731 # PliaNE - WM PHONE - PHONE - CODE HSI lig 00 AUTO INSI,IRA= I/O PLAN COW D30 NHS CO MW ASSISTARM/111110 1 POLICY# 22875428 s GROUP 4 s GROUP# u4 AUTHORIZATION# 04 AUTHORIZATION# (lt1 ADDRM- �* AD RR S PO BOX 69360 HAISBUING PA 17106 PHONE# VERIFIED C PHONE# VERIFIED f- SUB NAME 1NARSAME ,ADIMA MIA Y E SM.NAME: 11ARSAME ,ADINA A Y REL IQ PT S PRIORITY 1 REL 70 PT S PRIORITY 2 PLAN CODE moo PLAN CODE INS CO I PCXICY# i POLICY# i GROUP# g GROUP# R AUTHORIZATION# * AUTHORIZATION# A3 ADDRESS 114 ADDRESS III C PHONE 0 VERIFIED N PHONE# VERIFED E SUB NAME MI i1 SUB.NAME MI PA1Of TY PRIOR Acomm SOUPTION ACC.DATE /7WX 1 IND. PRIVACY NOTM� A FELL OUT OF CAR LACS BAC 02/09/11 15:45 A 0?0511 BRi 01 WK HOX ACTIVE AW# X= 81m UDLER DMITrM DX. I ADMITTING DR. ATTENDING DR. DR. 180019 ED GROUP 180018 ED GGItOJP 1#BD19 !2MSTAPP A FSLL RT ARM LAC BACK RT AN XLE LAC AMBULANCE ONIDIIJ!►"FixD OR BI,S MEDICAL.RECORD 3! 774 WAA ACHE-ilIfIB1A A 6 F �ti w .! t .� G, i .; ^y��;�.Cr.:i fir-. ,�: 1 ..w �i,t �'t s t ,e• sir 902i 1x74 l Ja 3gM ,..y :.. iyti� F } Addilt Dwt 04-Psb�Mt>tl Pro+vida.9%,G ADM > a J. �, s•: . o:: :i .t . Arrlvel Info: • Time of Ttbge 16:46 • Reason for Visit Pl fell out of moving van.Speed minimal-rolling, Denies hitting head. Scrapes of left hand and right arm and torso. Right ankle swollen. Injury occurred approx.60 min. ago. Pt able to move extremity. • Langaoge SpokwAlIndenetood English • Mode of Arrhral 8LS • Means ofArrivai Stretcher • Accompatolad by Family • PrImmy Ctrs Physklon Sadler Treataesg Prior toArdvok Trostmew prier to arrWW. • Trasloa d prior to arriving Yes... • Systegc BP 110 mm Hg • Wants&BP 70 mm Hg • Heart Rata 144 • RespRale 20 Pres •. P Complaint mu~rm llnjury; Mullisydem. Triage Lev of: 4. Vital Shins: • Tamp FahnmIm it 96.9 degrees F • Tomperolwo tympanic • Haeat Rain 97 • 5ystsBc BP 133 mmHg • Diastolic BP 77 mm Hg • BP ftrA salve Msaa 95 mm Hg • Reap Rate 20 • W2 N 99 • Respiratory room air Pain iAttsrtwerntsnt: Assessment: • �7 patient experiencing any Yes... • Localion Lower Extremity (iss) right ankle • Quw ty Constant • Onset Minutes •:- ,a na, � � �� tk( r k�, �, .4; •�. . `rte t Fn �,�r .... .;`ta i� r stYt.;.i:!it y■ r ,i 1 - r i.:,,.'[•r .''.f: :r a . .. ' , ,•,p.!•' .:: t :'• i' f. Z t , _r n. AOM Imrnuur�e8ouarr lmmunitallon hktory No recent exposure Current- pediatric M*4kgl HMtMr: Metkal HiatM Dohik: • Dees the patent have any No mad led problems? S ! tex. w S rgh ai H isto ry: • Prwlew Surgeries? No meet Aomnusarrnnnt i iwcsrvoeEtisrr• • Airway Patent • 0resthIng Normal • Orculathm/Slrin Piny Dry, Warm * Mental Status(Pori:) Attentive/quiet • Vlsuai Acahy N/A • Triage Irutsrwntkns None ED fts araca Dirst6a; ce • Advwce Diroc*e Not applicable (less than 18 yrs of age) Abuse ulrw: Abuse cron: • Paliant stag physically, No , emslior ft,smau ly hurt &*&or threatened Additional Question: • Do you auirrontly have any No thoughts of hurll"g yourself at others? � t+K: • No Known Mwgiss: Triarte: Trtsge Disposhlen: Triage Dkpeshion ER Elactrenic Signatures: Dabs D s Lj(A11 gonad 09-Feb-201117,53) AmOkwo*Aroval Ido, Tvatment Prior to Am val, Prevent` krinta, Vaal /rrmruuaizations, Medical Hia�t ��'►A Pain Aaaeleatmeni, ory, Surgical Hiabq,Aaaoasment 3 fntwv#N=4 ED Advance Dirw&e,Abuse t HosplIW �.5p! jy i Scmero)g,Additional Question,A*rgieA Triage Last up&ted. MFe&2011 17:53 } F` law -.i ";.` •',`�t, .,r 'i s� � ; !:..r ;,.j l,Y,t: :.4:�ii�Ii d�+! \7Q0 i{ WAMS P. } 7 Complete Blood Count+Automated Dili Requested:09-Fcb-2011 STAT Order Source:.WrirwnTax1Rx Bsten,Melissa I(UQ Comprehensive Metabolic Paael Requested:09-Feb-2011 STAT Order Source. WrittoWF&VRx Baton,Melissa I(UQ Xray Ankle Complete 3 Views Right Requested:09-Feb-2011 STAT Order Source: W rimnIFaVRx Ream:injury Batm Melissa I(UQ Xr•sy Foot AP IAteml ead Oblique Rigbt Requested:09-Feb-2011 STAT Order Sourcc:.WrineWFax/ttx Reason:injury Baton,Melissa I(UC) CT Abdomen+Pelvis wttb Contrast Requested:09.Feb-2011 STAT Order Source:.writtn/Favlx Reason:iv contrast only,injury,fell out of moving vehicle Baton,Melissa i(UQ IMMTOIRY 111Et Qt1�A 170sapood1w—Ansk11-A W '(Approptbts fltft Coo •Mmatrisov unteos rrf Mmdld pe xas vemponse o ODhpaoc Oh iv usido �)(G $mss ©Gonsolow C]Hal OTwMag DEoclVmosis C38um [Rebored inartm tions Extra city oior 11nw nwpmp ia* C]Pate DFlushert OPunckn Wound uwhee*g L I R D��d OGyatow 0Agilatsd wools ODwky 0ma" []Lacwaftg Avulsim ❑ralesldwndd L/R Skin err ❑God Dur"opemlivs QPeraident acyaw* Coos uoough DWAa F,., esgPll wONOpelp. C]VerbaMy Abuav11 OCoerbeaMe Inapp X40 (9Msft C)* OprWwWs Edam a WQ CINo OAmdow ocrft cryingt sww" I#1101111 []Gw*disd Z)02 ttmin vie+ Odor n q OYes j oy (conk"d Ct Moms to pan 01 alt 13CYwwbc DW Gorwoled Ecch,me is (Yes C Cory Dcamw cm Stmt Gwow pm - f lheadavohe JPERL R L Udw iss Ws :swdtal OMoni Wm yeen: uchest pan gym usdK node Sire M,,,_ " 4" MQT13R gESPON8E VERBAL � � aearrge _ w 3n&*pain Pi VW U ;3 3 To atsas 6 Loc 4 t]rbtesd uwprKl Z)vapbd -- Savedly_„_ 110 JtacW droop Okled J J Z To p&ovrrwd 11 LFladonmswsi 3 bawaplilb UDyernte uwrprel bbe" up" JconeW Usharp ❑numbness: Fined J u INsaspase 3AbnovdApom► wads --"Mom Uway Uedema: _- ClinamiWnt Jdull Sluggish u O 2 AbowW Err mim 2 lncwpa**W Jrmwftn pre0er+L-11, __ Jbuming :tpmwm uw6dou s: notFnt dvso u i No i"M e 1 No Fkej* ^ umar: LMP JJVD US08 c1he" ON/A QCVWNY mm: On"" u0su k �Mwllw arepid Jrtarradiadrtg ODerdsa pw hpip"m u0unldonl inlet" Last 9M OAbdornsn tatder Udeiayed u +g Unaw►0 Jdianhee uvomilMtp Dconapationa nta*nssis dowel Sounds Udistended Ubm Osofl uc eN tender R I L ON ❑Pair► L I R __._J Ears Now Tbmat tfGr - tumsd vision L t R R,_/ t Main LIR 7oongesim Usage Cornowd 4y- _,,,RN TO*: ado"vision L I R Uvelh tens Ddechirge Jds>mp Lidmoing bW w as& wink pawl uPhotapltabitt L 1 R U0dwr. JEpiftdo L t R UdyepIfte W X1 pro0eidur11 seplafrsed rr D t lisle Start Slop *0 SdiuYott Sz. Sib RMe AMpt Cond kYWI DebX Time Dng l Dose �. Roub Site irelW V7 / ! ove It b Dated Time NOW " ,� Signt ure Irtitisi 7 to I DtlTC?M1NMD taaaompartied by:u 30 ]11tr"amiiy Jot w f pia Adfib A" Jwk Jambulwm i + G X /^ To: taWM JMM q horns Ua VA JOFI °D uodw. Dis�bouetions gNm tcc 79F ff4lxd * ,j nt UFrutdy aY�amra uoow _ _ e j�/ j /ji Roorsi void mooKis sent to bw ;d ioftg*"dame to t>�rty► iRL�c wt•t. i�t i TX4 TO. __ Utmnsfor cheddist cwno to ucrwd ODe+creased to nxn w C Ind v��e J acme_.__,,,,, _,JIc so G i Fah�t,PA wARSAMS .ADXN& k 6 F ER1 06/02/ :004 John R.Dietz ECU ED GROUP 697464 NwmbgAwmnwWNow 687666 02/09/11 39115111274 20S-Scu linos Itth NOV.uW 1111"LL00b i ALM: t I [ I ESR l ]The*** [ 1 !I ABOrS� ! I Aaekrrs(SACE)l I Q uom t ]MvWnbolyiic Labe I I EKG [ I Peak Fbm 8#bWAfW Rasp.Tx. [ I At"(ALCO) [ }HOGS ( l Tox Screen C ]rn u rmin. I I Respiura"Tx ( }AmyW*A*ooe I I Oserraiaiive [ I We Toz(DOAS) j 102 Satvraibn [ J APIT' HCG9 t I TSHR [ I Be" i 3 w i l TrP SOM-.---0 0+unft ModW&VM/we t&gift I 1 t9ood t�lturae j }tithiurm ( omp ( ]Lives Ix" I I Type d SCION 1Me 'Z C6CP t I L1Aa CMP [ IPM' t IUdmC&S ! I MOM.TNT [ I PAenobwb I I LkkW HCG [ J t I Kp I I we&w*Aba Tool eM i.oarde [ )Td [ 1 09min Soq4o I 1 WC Drug Swear # J I I t I eowe frid for.m ( Abt .Sod" I I Imes R L I p I Clevicie L I I fS Song [ I Cay.spin-Routine{s v*4 i 11Rardlbe r a [ I Cay.Spi1F,All'" [ 1 NOW 0►ti [ I Cerv.9*4-po l"sat [ ]Orbit R L # l Cheoi-Routine or Paiebe [ I Pelvis zol t I EWW R L [ I P"ftfam NP [ I Fared [ I Rfbo R L r- ( I Fw w R L [ ]shoulder R L tlFmW RL ( Ism TT C- L ( } mum Fwrwm L I I T/Spkw ( I Hand R L ( !Tib f fie R L [ I Hip R L ( l Too-R L t l Hur wA R L j 1 wim R L [ I Odra: Tir WCRTAirt.._ REASON:�lLti ra .t�.�..t.... U*Mooarat CT: (Waal t [ I AbdOnuen Al mmomm 'Avid W) wo I l vQ seen � l 1 DoPIiMi► r I� WO [ 1Ed* [ l QWlMl Ida ( I Chad w wo cabigiram ( J P" I I WA dm*for PE Cr o.wad bran* I I Tom+ I I Dow. [ I fMRI Scan TM%CRTAnL REASON: j IOMCftWM x I AAW I I CAM AiGlrMrrrM /GROW. { I Sole ON"AG Rapid [ I si od C&s ! I CanAaaUC3NW [ I sfool O&P MON(M TIC�11faNt: [ I Chlowift t 1 Saw C.Dfdklle I 1 CiC cuNuea [ I Tiitironarna t I ( i I wound C d S ��.-- • t 1&"CSS [ !Clow PHYSI"CHARGE FACILITY CHARGE IMtials: Signature: FA MA I I I I I Level t ( I AaCWW i 1 Laves I ( I N " InNals: Signature- RNAAA I I Ili �f I I cue I CWTX4 hM ll [ I N [ l Level N j 1 Erearded Hrs. ]Laves v•-,���t ,.`2_�,`��j L Than: 171094 17108686 �jwzm& 6 F 17188858 17280767 WAFJJA ric 06/02/2004 0 1710% 17102385 ED 1 GROUP 487494 (`1771j��/ 3 /'� 17100652 697496 02/09/11 39059274 MN TD �fiV¢.t�`tt i)Ilfl '�!�'.V ,?1 ill 7 reo, y. lUi C:4rrm ir :ttn;, nv�, I I Pennsylvania EMS Report serela wine 3t.tltd tilt NeM M&&Tie PCI 110 Oft c3tlttw�llwco.�,,1 A86"4147Ma>gQ IKA 11IM41, Ismail k46W L.ta01e C Wl!,Mwbipiit)r 6t lrti"Zip PW tern.Ne. Woo 3AwrlrwOW Ch nk[J43 VYI&M Man Rd . CLMWA 111D,MWO1reieediip!'IVilli M I" PA 17!11 %"*NW cm AdW A VISUM CI., ttitl"r ckn Rwr to"?$ a S&etAtMrest CI: %Solew.Jew EMT 11034 15 0 Peirce Ckeie CJ: 1r CW S" ZIP w PA In" C4: }.► AS PMON& rdmo"Ce"IM: CI Mrlw ... Q • ifo"b 6 Yaia (443)U3-1731 aVIN&ONNOW SKMSN.Ne. IPI.WdOl 143 !!9.01.0201 I Oat Ot-bW aoa in rrhwte Delrer's 143363.9 143MAA t43 IA 143391.7 T""Pr tO A O VON A=W 03 — Ratatrp'tirM: 2 911: aartmtoeM WMOrearbMat )rillTlate: S lli p*k 13:03 TOOd.WOFA16 by Na K.S OS T1t e: is tweak., 15:47 iQ;—Ne me& Tnmprrt M*h 81111 Time 21 An+m&cm 15:32 to Li t:rtl Shea+ No Uob w S4eas Dudes"Tone: 64 Crrttet: 15:54 PMbW Card! O oft kne label Comm a at Fad* ToId TMe: 110 94W Seale: 16•.10 1Nittrr ,oy1 TbM Old of O Arncc 16:31 Q° °: Mvrllsik: 17:35 J >W Qoaiitrss O I*We h• Certart 1Nds: line Irer rledltf ARnMentmift MDA PAQit: NOW 1PW meNter l I Narrative Ambulance 64-2 dapw*Awd to 1345 Williams Grove Rd in Cumberland County at the Wan More Bvaul"Cbumh class 2 for a 611 victim on Rebnmy 9,2011.Information farom CC 911 on response was of a 6 year old gild who hU approxi moely 3 feet off the step of a van and had dasions on hey 1 • Andmism 64-2 arrived on scene and*We glee d at the door to the church by a fi mfl*r fear Co 25. He advised that we would only need the litter because du patient was to have only minor it wkL The patient was found sktbW upright in an office chair with her right Lag ekvWd and a bag of ice cwming Printed On:02/0 12011 ISJO Frari6ee thiS et lAWeW*c)1"4.2011.Mod Mgft bm AM Rjgks Ratero4_ PW. I of 4 rep. Y. L�1I 0:�+!I' 4 L Pennsylvania EMS Report aerrireta�>eM uaa No PCR tw. DR* COW RMMe Co.Na 1 A 1106161 ptaCa�i} h~liee bskotnlirlL aNW6te0riaty3'1wrDer t'8A! A&U A rlhlilrMalc a6aa)JlA60a 96!Ol 0261 143 t her right ankle.The patient is CAO at this time end is upset mbd crying. Once on scam crew assessed the patient and she qVm ed to have only minor abresions to hct batch, abdoeme,do firm sod a mwotlen right ankle.Thee patient bas sWW b calm drawn trod she advim that only het aside is really bodwing her.After all information was pille rod front the pwPIe ea SCM who witrres ed what happenaed'the pent was carried frets the chair by C1 to dw liter load sat on it in a low fowlers position and wcurW with sW ley straps with the sick ratan placed into the up 4M.poe him At this time a f e ty nurse obtained the patient's vital signs sad advised EMS of her hWkW Olaee t111s was completed the patiest was wheeled on the Nitta to the waiting ambulance and placed iWe and prepared for transport. HPI The church pa"advised that he had a gins of children in the chulodr vu and was driving in the parking lot.He claim dot one of the dWdr+ett opened the side door and the pntiart was not whined and fell out and onto the ground.The pastor advised that the vast was only rang when this kgpomd at appnlncimately 24 MPIL The patient umb led to the ground at this thane. She ciaiaas that ulna did no bit her head and did not lose emociousnesa.Iaanediatel r a>to the lbtl 6*pedcat gat to her feet and Xarted to cry.This is when 911 was celled. Assessment The patient is a 6 year old cooperative kmak.The patient is CAO stand denies nay toss of ss. The Am is w ra,pink and dry.The head is as usur calk. The pupils m 1MEAML vd&so hkaW or double vision said the hung sounds are CTA bilaterally with no reported Aaftess of h ea&The pstieat has>m cmnpisiats of c hw pain.The patient denies all of the foMaawing:had pain,oak p*aaom vnnikin g,diarrhea, or iamducace.Mo paw qua good Pik in dl askeWWW acrd no headache is noted The patioart currently complains of podn fiNOm abauions to ha'back,"iiiii ea ad fl*fiaioesrm.Tla>e patient also has minor.swolft to ha A&aWt#e wbelh is beinghread w*an im pack,Tic patient has no other complaints of injury or ilhmss noted at this time. The patient was transported to HSH at a Imn ernergency rate with an iwpnwemcat in the pa sleds contuse.Tho patieatt claim that she is feelilag beer and is not in ar3 much paste.An ongoing sucamew was compkted with no other complaints of injury or inness noted.A BLSN was made to HST via radio Upon arriving at HSH the patient was whedled from the ambul ttaco into the ED and ilk to take the patient to eanm room 26.Owe inside the room the patient arlid kom the litter to the am ram bed. A repot was then given to the RN pimm with all care and paparwmk ttessnsfe-ed at this tune. Dix to the langvW banicr with the patient's mother a HIPAA signatssare was not obtained. Pdnied On;021O NI1 11:30 lkoviater EMOM ac~)IM-201 1.MW Wis.Inc, All Riou Reserves, PW 2 of 4 I I 0:4crlV. vl I .LIN I MV, L J 1 fleunsylvikWo EMS Roort S9n*9"am UeN Ka KR NOL Dak I Cldaw um Co.NO.l Amb 61-21670621kt 19LS 1106141 1 tulltut t+bmt Dutt et�rth sum#Kwicy Naeba lBAp � AMA Wyrere g6103/266� !!1~p1-pt01 Ui Al MbullnLce 64-2 dwed,available Cale Edmis lIt EMT PA 108275 Time Events !'rarfier CMbw1M6 1klS rl�cle M:31at0:1i;Y•r.:110�]0{btst�l c1r6?:OCd:A13f6;Rash.611in: Oia 16:23 Vick Pelisc tM;Reptc�t1.P.:tORIW(MaNrM Calt);t)C5:MS/d;Rap.61XM1: ttMicser,Clssre ltaet d hemien:ft I i PrWW CM:0?Jr0W 11 11:30 der SON lkpeit3 Oo IM2611.Lied MedK lee. Alt lift Removed. PW 3 of 4 1 Pennsylvania EMS Rgwrt I SerrMe Pp�e Unit Ne K2 No. Ddt Maw Hot Cs.Mo,I Amb 64.2 l 69ilOQiM2 t 8LS i lMtif�t1M t DON eta* sumiteu*Nvabu IMF A w A V mute 96lQ2lt00i l99-61-02@1 143 abMsim 0bmicn I I S i mcion 6wd" i r r Pth*W On:02MMI1 fB:30 pao EM&N il"Uftv)19M4611.Mod Moft AM AU 1LWU Raervat FW 4 of 4 I i i Holy Spirit Hospital Depaftunt of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717)8724900 PATIENT: WARSAME, ADINA A DICTATION DATE: Feb 9 2011 6:50P WW: 6674M TRANSCRIRTm WE:Feb 9 2011 6:46P PT CLASS: E ADME: 3OM74 ORD DR: SUSAN DACOSTA CRNP ADM DATE: 0210 2011 PT TYPE: E ARMAL DATE: DOB: 0810212004 HOSP SERVICE: ER1 LOCATION: ER1- ACC*: 4242525 GENDER: F —Fki Report— EXAAMNATIONN: FOOT RT 73630 –Feb 9 2011 COMMENTS: Exam:Three-view rat fact. History:Trauma with rWd toot pain. Finding: 3 views of the right loaf were obbrted. The ossoaus structures are skekt t immature. There is no fracture or dMocatbn. Salt timm appear unremaskaW. CONCLUSION-- No fia cIure or disWWw at the right toot. DICTATIM•Y: BRIAN MCINROY MD 1 DATE OF IMAM: Feb 9 2011 110 mm MY: BRIAN MCINROY MD DATEMNE: Feb 9 2011 6:45P l i I b>���by Out TO P ihs bed and aafsst POW caw; routine daytime � 1#UIl1 wadslsy,ws oWmd and troN*o"ft asps.a Qum Re****am be aa+taood at TV 7834944("*SW IMAGING Ho ftftk AMr M*j*,a Qwntum RaftftW am be MdW by phm 24 hom a&y,Waft drys a week d 717 W- i' i a CiIMF1fI WIW rMs nlp0irt contains privNe pdient into .N you ha+re received this ropart in error.P anti 717-9T2 ti immedwl* i corad.rcwaiy Wsdsiow—The WOMM&W conbined in this=MMW i;WW may be 0006dow,is k*WAW hx the use ef the fedpieat nanW aboas,and may be tspaay pri arpsd lift rwr 1 of ft enssstlps is not the hiMrded na 1 1 you ew hooft 'Ift that any dh"NW hftn.dW MbVdN,or oopyhip d" aarrnnunkdian,a srq of its aorNe�t,R drirAly prdrlbilsd.q you n�osiMSd this a�ore+nwniodien ht error,pisirrs nsssrid thht aonMrrwrtic�on to 11+a sender M1d doft Mier onlpinai mmsye and any copy of it ftm your QWVt1 M'srihn►.Thank You. "I"SWAG"Consuftam Pape I i Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp HUI,Pennsylvania 17011 (717}872-4000 PATIENT: WARSAME, ADINA A DICTATMMON DATE Feb 9 2411 8:52P 0W: 887486 TRANSCRIPTION DATE:Feb 9 2011 6:48P PT CLASS: E AMEN: 39059274 ORD MDR: SUSAN DACOSTA CRNP ADM DATE: 02109/2011 PT TYPE: E AIMAL DATE: DOB: 0610212004 HOSP SE'R1110E: ER1 LOCATION: ER1- ACCO: 4242524 Gomm: F ***Final Report*** EXAMINATION- ANKLE RT 73610 —Feb 9 2011 COMMENTS: Exam:view right ankle. History:Trauma with right ankle pain. Fincin aE: 3 views of the 099 ankle were obtained, The ankle joint is mairttainecd and congruent, The osseous strudwas we sksletailly immature. No fracture or diskedation is seen. Soft tissue raeft is seen about the ice;t ul.oMus. CONCLUSION: No fracture or dislocation at the right ankle. DICTATED BY: BRIAN MC04ROY MD f DATE OF EXAM: Feb 8 2011 SWM BY: BRIAN MCINROY MD DAT'EnWE: Feb 9 2011 6:46P 3 *+nom p by�lrrar*m was. To 1> the WO and eat p*W crams MAN*daytime � tum wSd sY,wg**fd and hoofs on•sin oovarape,a Qrrarfturn ft0ologiN icon be 000MMti at 717442949(Holy spirit t 1M A G t Y G Hoppigii}. AMr robvi ly,a tlW%wn Radiologist can bo raaohsd by phom 24 houng a date.aavarrftys a weak at 7174V32. tit X CONF10NNTAL:This report cwftim privala padsnt intonrradon.it you have rocol ed"m W in error,pliino cal 717412.4941 imrrre r. Conn-P WsMlat OWWimer:The inluwaiion oonlor1 In this coflIM icrdion may be 00"W mist,is hflsrrded for the treed tho'-`41 It neared abofnt,and may be 189 ft prirMsMd.it 11rs oawMr of ft nosupe is not the hftsndad noi)iarrt,you am husby notilhd this any diownftft,dl Musk a Copying of this comrwniadion,or any of its conlwrts.is*k*WWWA d.if you mew"this corn M ic"M in ow.pled m wd this oanmur+loi w be tm senile�d deieis M+s o ftkW awssep and any copy of it front your cornpftw system.Thsrrk You. i irt+tagNlp�vlatis consten Pepe t Please List AN fdgM Medications: (include all over-the-oolunter, vitamins, samples, herbs &other supplements). Please keep any medications with you and show them to the nurse. I�r of Mu�dlcation Da"p.Route(by ,cxeam,etc.), �� toek 11lM� Pnuyuency aim is Taken ❑ Patient has M a ,own*%medication Iist that Is copied and afrched to Oft iom. ALLE*tNES>i?""No ❑ Yes,Nm aN al won and mctMns: Allergic to Latest? d No ❑ Yes Source of Data: ❑.Patient ;alFarnily vdeEMS ❑ IftO R ❑ List PatierWs Phaannacy: PaderWsFsmilyPhysidan: 'l �titlti,f Patient's Signaturo: Datetii1m: Farndy Signstuee and Relationship If patient um bl*to sign: (3 Patlent unable to sign and family not available ❑ Unable to clarify medicetbn,dose,route or frequency at tlnle of Interview Practitioner Naas Printed,=Name Stamp, ( A/t"RNPlRN): Practitioner Signaiun(#NDt�CRI+� E HOLY SPIRIT HOSPITAL Camp Hill,Pennsylvania 17011 VNItSAM JWX► s 6 F Tkr*kmicw [ ER1 06/0212004 Medfcatlon History form ED GROUP $87406 697486 02/09111 99059174 Forme MR 204 Row.10107 FMC 101011 White. Chart Yellow: ER Of Pink: Pollen! ExitCareO Patient Information-ADINA WARISAME -ID#000639059274-MR#687486 0 HOLY. Holy Spirit Hospital 503 North 21 a Street Camp Hill, PA 17011 SHOSPrr,AL (717) 763-2100 The spirit Qf C:urt"Sc EXITCAREQ)PATIENT INFORMATION DISCHARGE INSTRUCTION SUMMARY PavowvMit fabrmatlon: :ED Grou Disc Da1elTfrr�:21Q12011 9:39:10 PM Patient ID:000039059274 Pati�t Medici Record Number.687 Patient Name:ADM WARSAME Patient Gender.F Patent fit: Patient t. Patient DOB:6W004 Deport meat:ED Patntnt Phone Nun*er.(443)653-1731 Patient Address:666 CUMBERLAND POINTE CIRCLE, , MECHANICSBURG PA, 17055 Responsible Allah:SAMRIYE LEYLA Patient Emed: Visit Start Date:21'12011 Dian: Other Providers: 1 illy hWjrutdn Stwwft Pr r�ided: Ankle Fracture-Brief Patient Ins4ructlons: FoIWM elk Primary Follow-up Information - (0000-0000 111 02011 ExltCsre, LLC 2/912011 9:39:13 PM JOHN R. DIETZ EMERGENCY CENTER DISCHARGE INSTRUCTIONS HOLY SPIR SPITAI. } ��. 7Le exanrinuion ed haws received in 41 Caller hoe been emersency Mums.rdy.MMUCTIONSCHWICEO'intended to be s wt erfw ro provide cae�lWIM wAdkw are.If Y49 sew ptublans ur canNir t you physia�a tills Caner,A01_LQW Palleall Info.naatiort:PeOwt Iraforn►aNalt Sheets Contain latportant Information to Review and Keep. (}Abdorainai pain ()Corneal etuasiw ()Headache ()Paton Management ()Threatened Miscarriage O Alcohol reaction ()Croupmtonchitie ()Head Injury ()Pediatric Head Injury t}roothischg ()AN/t*reaction (}Crutch waiking ()Hype+te ww ()Pediatric URI ()URI artd Colds ()Asthma (}Diarrhea and VomitlngtPed.Vamifhg ()immunizationlfetanus ()PIO/STD ()UTI and PyelonsphrAie y lea ( stmo�e }� Bes AniM Wrwact ( DnWAloohol abusWaddetion lablynthilis Re 24 Hr.Pharmacies Bum Febrile Conwulslon lac eationn Seizure Other (}Chest Pain ()FavedPed_Few ()Neck Strain' ()Sore Threat ()High potuslum coniaininp foods t)Conondivilis ()Flu ()Nosebleed ()Sprains and Strains (} ()COPD ()Fracture ()Otitis Media ()Suture Care&Removal WOUND CARE M EDiCATKJIM 4- May gently wash ow wound in 24 hours wth soap and water or { 1 Cottiinue preeene medications owept: -r (X}C d,mo g—4.._iwnw daily.Redress with Badtradn/Neosporin V ( Iroten)or T as needed br pain,hoer end,lwriis dwaing or lea k open if advised. ✓ to peduw for age and weight,etc. }Keep wound dean.dry 7covered ( )uncovered { )(Isee the following medkirhes to padalle instn4lons: t: t.~ SpRAINS,STRAW&WRn"ACTtmm 2: j cethe w*xed part let da"kto&=swdbg. 3: p �t �f Ira to nature ( }00 NOT DIMYE O�pATE�ill HILE TAKING: Wear spill V At et times until foAow.Up- ( )For acdvity as needed. use$11111111 for:pert aWdtes: ( As needed,weight beating as tokwad. The prescribed arr>>diotftdkiedkatbn,may lattice the edectivert®es tip t all Urns,NO WEIGHT BEARING of ntediaidbn you are currently taking.Cheek package instructional or consult with Pham>ecdst. NOCK41loACK ( )WON oNVicd collar for support for_..days, FOLLOW4JP This Is our noorrhmomkfta tar fa wo-upi.it your ( )Reet.avoid bw drhg,Wft airarkous ac&*for—days. pesos AS POM tlsqubne a pthyddM 11111 oral ter agtaotady eamuwti«sn. ( )Apply moist heat for minutes Emu daily IT IS VOW HM OLffY TO OBTAIN TM WOMSARV APPROVAL. be*"In howm $A-Follow-up with: ( )Urge Coulter ( )O c. ADDITIONAL M1 rlitUCTWNS { }F Doctor or ' 1t) 1' O Encourage t inhka b " 'l t f jd_1g�1 for t 1 74 ( ) Char w liquid dkot frost o did m obtated ( }Take the foiksNing tad results to your physician: ( }Reft m to work on ( )(230 ': )CMP ( )EKG f )X-RAY REPORT ( }DINERS ( }Uot O ty iota: . IF YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 783.2900 Reakicliom: FOR PHYSICIAN REFERRAL. No wn4poril { )Call am X Possible fix Ram ( )Follow ys puetorea on s F um. ! up your Rays ogyr Department prior to t )wee'eye patch for t�,m, your appointment.Call 763 M to halo firma ( )t nose u*.nnaaas,pbch mare fir 3 rrhirhhAes ( )See.your OW*Ian or spactalist If not it Vored In days. rah inlehuety, Ilion ri if your not n Preliminary P-� %hum b Emergency Center 0 you feel your tendan is worew tg, { }The ithterpesUeUrtrh of your X Bays era prMmirhary readrtg. Your Aline will be s 4mved by a ratAologiet You or your especially M Pt"10116n wf be contacted N there is a dump In the diagnosis. i i ( )Your blood pleasure was elevated,Cho*with your ptlysicisn, i A copy d your dwtatsd Emegatwy Roam Repot is wdlsbte b your Physician from Kcal QP2e1111)),it net already Mo. ba r a iR � I hereby scirwiviedIl•recast of these Instructions and underaianm ttharrh. ;� I Undo o&W trod I prawns had emergency ti+Iletrthe+tt SNh(am that I may r be released bob!*ell of my medical pimbiams am farfawe or treated. i WIN at mp for tallow-Up can as i hew bow intrtrrded,b is my responsibility to nobly Printery Came Pthyairarett d ills visit.. SIGNATURE: r•• SNIKATURE ' PON IG Data { }P PEON MINING tNATtN1E: t)at. HOLY SPIERIT illit113TIMAL JOHN R.(NM EMERGENCY CENTER 5M3 NOwM 21ST 07=r CAMP mu,PA 170i i-2 1B(717)9724= ( }Satvan Atfaae.MD OUNS ( )K4vb1oScsa McGww.DO O1ON9 t )David Zimmerman,MD 005636E ( )Therw William.NP't'Ftkh5lm c )Romeib Mesa.MD 016727E ( )Prshpa Madan,MD 051514L ( ) ( ) ( )Nikoln J.Baram DO 09000697L ( )Aaron Palmer.MD 423830 t )Lorraine Dock,NP TP003409b ( )Dames 8dowalo,PAC MA0DI$761 ( )Lake CThetlea,DO 01313145 ( )Lawrence Pat.MD 0395Z4L t u Susan DeCosta,NP SFOO76248 ( )William Butner.PAC MA032332 r .•t; ,i...n.rs.... ►urn nca�ttsr r r c a,r.w.,...n &rn AIA 1&4C r Dan,n...r,.,, va emaasisrs r r Uwalrw ♦ TUD. K. asr►u snMWM_ C>J CONSENT TO MEDICAL TREATMENT I HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital.its agents.ant employees.to the rendering of medical care, which may include routine diagnostic procedurds and Such medical treatment as my attending or consulting physician considers to be necessary. 1 also under- stand It is customary, absent emergency or extraordinary circumstances,that rc sutrstantia',procures will be performed upon me unless or until I have had an opportunity to discuss them with a physician or other health care professional to my satisfaction. If I am a competent adult, I have the right to consent or refuse to consent.I understand that the practice of medicine and surgery is not an exact science and that diagno- sis ohd treatment may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital. I understand many of the physicians on the stall of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these facilities tot the care and treatment of their patients. Further, I realize this Hospital is a tesching Hosoitat and at the Hospital are health care personnel in training who,unless expressly requested o0wirwise,may participate or may be present during my care as part of their education.Stilt or motion pictures and dosed circuit monitoring of mhent care may also be used for educational purposes,unless I expressly requesf otherwise. I understand that in order to ensure a safe environmert for patients, visitors and slat'all property on the premises of Holy Spirit Hospital is subject to reasonable search and/or seizure at arty time without further notice. / RELEASE OF MEDICAL INFORMATION 4 I authorize holy Spirit Hospital to release to requesting health insurance carrier(s),their representatives and auditors,a any referring health care providers,such diagnostic and therapeutic information (including any information relating to treatment for akAhnt arx! �++�tance abuse and treatment gi 2ffiMbWM disorders. (or cgdidontial iJIV related titian&#ion,as may be necessary br them to determine benefit anti- tternent;to process payment darns for health care services provided during this hospdafiza�r/treatment ,for continuing care&eat. ment,and hospital operations.A photocopy or carbon copy of this authorization shall fie considered as~ve and valid as the original.The undersigned also authorizes Medicare,when applicable,to release to another insurance carrier,upon their request,medical information need- ed to make payment upon that claim. !understand and consent that the manufacturer of any.mplantable device inserted by my physician during the course my urger"rocedure may be provided with my identification information,including social security number,as mandated by Federal Law. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the Notice of Privacy Practices.The Notice describes how my health information"nay be used or disclosed.I under. stand that i should read it carefully.I.am aware that Cite Notice may be changed at any time.I may obtain a revised Notice by con tacting this Organization's offices or on this Organization's website at www.hsh.org. lniti � INSURANCE ASSIGNMENT OF BENEFITS !authorize payment directly to Holy Spirit Hospital and my treating physicians of all benefits payable under my insuran a.I understand I am responsible to the Hospital and physicians for all charges not covered by this assignment. STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS,PHYSXMNS AND PA ENT I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished roe by or In Holy Spit Hospital including physician services.I authorize any holder of medical and other information about me,to release to Medicate and Its agencies any information needed to determine these benefits for related services. Initials MEDICAL ASSISTANCE RECIPIENT My signatures certifies that I received a service or items from Holy Spirit Hospital and Dr, on the date fisted below, I understand that payment for this service or item will be from Federal and State funds,and that any false claims,etstements,or documents,or concealment of material may be prosecuted under applicable Federal and State Laws.i understand that certain grits and rocedures may not be reimbursed by Federal and States funds and that I may be responsible for non covered charges.Also,I agree that time of service,-if l am not eligible for Medical Assistance, I will be responsible for balances owed to Holy Spirit Hospital. ( is I have read and understand each of the sections contained a bow.I unew*tww that providing the authorhaftW cc resent odnt�ned in each of the ab wa sections ,l inn agreeing ub Ali .I hatra tits ty to ask"stlons rspatrlIna such of Base sections and all such qusstlone to"r Wn, Signature X0, Witness Relationship to Pa Nte Ajur nme pad, HOLY SPHUT HOSPITAL CAW HILL,PA 17011 w�►tles�►t>fte ,u>'x>tiil► a 6 F CONSEW FOR TM-4TMENTt RELEASE OF INFORM477ON ER1 C6/02/2004 SD GROUP $47466 114SURANCEASSIGNMENr1' 687486 42/09/11 39059274 _ T R 16 Pediatric Injury (5) —Racoon Eyes I Battle's Sign . o evidow*of _so(t tissue Swelling. DATE' TIME L 20 O on arrival trauma _"p laceration n t foxier trauma FJIAS aiatanarb _EIMS/Irrivef HISTOM : lather pia — AGE M HX! EXAM LJMITED BY; .A4 HPI orw to arrwal home school neVibor's street see diagram work park/playground -twwor _vertebral P terrdertsesa dws w- ROM' muscle spasm J decrasW ROM mwk" _pain on movement of nedo f - — !snug pup k L EOM entrapment J palsy maid moderae sevwre =.�� ——subconomctiwl hecaord age— If - 4 conjunct.stag _--pals c head w * ' immiea W — —corneal abrasion/hrphema clhsst -_ scam nml retinal hernorrhaoes back Jbww �YaGia t — to AIL t!►ljl+/1ep ye: a,,�external _named septal'tteparoon+&_.. f TM abscond by wax- & shoulder UE hip LE �rnl closed nasal blood.-----. L- shoulder UE hip LE 1 no —dental htwry J malaccJwion decreed responsivws�s oy�aanpspsrent motor fadd asymmetry R --• -- ------------ c/ ory deficits Roar I sensory deWt. redo i ;�+ea 1 vomidng x-. -' _normal gale h I=a(bladder function ' ✓{s ra red, _raiirssss to ambulate/bear weight d t loss painful woot4 mrirt I walking �nml loss / ante i i skin laceration/rash_ I ' MKICYS chest ! r breadrh+K roc fever ilinsss ; tender _sweilbtg!ems___. orm" nqLaccapt>a marked sounds nrnl crepitus t n emphysema T I - ' SOCIAL ---------HX '---- exposure------------------ � � u'o^L Pew pulses _wheezes J'rales J r1%001�_. attends xia _ caretaker !cm ------------------------------------------------. ; _decreased cap re�U peripheral pubes—.— PAST HX _prior records reviewed capillary - sec aabows Tree I-- - tender no palpitations ABOOVAE i da- ran p/ see nurses rwa — ( d11) s� — ) non-anodes rebound I too darrrem.___ - VFBGDA/we nurses note Z/^°organomegaly no seat belt trauma — OTir llgrsenrant ttsviewed Vitals Reviewed mmuns.U'tD nml bawd sods' PWSWALEXM _stagger{PTA 1 in ED}J backboard_ RECTA decrowd rectal tone _ Mild 1 moderate I severe distress _nml rectal etaun awpt - hsme nsl�dw stool r than/ _fussy!crying J cries on exam 1 irritable_ P t`terM..w. tx7+awo,rawan rn 6 e i+-t�eadoa.t. tj&40w Wen ) c1c nxwM. [.c-e.ar.cf.. A-At�a M-1Nwd.sw. r�+ti►. c ere o>u"d _letharoc/weak cry p0-w�anaw ,.�ww wh.�•l•►�wr n "PAW) ee*aroused r>r- ra.r.raWr•• copy _poor consolability J poor intake suck. O I -2696 f Inc CIA*or Holy Spirit Hospital WARSAW ,11Dttlil► A /2004 F Camp t1ill,PA ERl 69748 6 John R.Dietz Emergency Center ED GROUP 87486 EMERGENCY PHYSICIAN RECORD 687486 02/09/11 39059174 Rev.06/22/06 Pape i of 2 Holy Spirit Hospital Department of Radioltogy and Diagnostic In ong Camp Hill, Pelmylvanla 17011 ` (717)972-4900 PATIEMT: WARSAME, ADINA A DICTATM DATE: Feb 9 2011 8:30P MRP: 687486 TRANSCRIPTION DATE: Feb 9 2011 8:25P PT CLASS: E A#llN . 39059274 ORD tRt: SUSAN DACOSTA CRNP ADM DATE: 02fi912{311 PT TYPE: E ARRIVAL DATE: 008: 06/021 % MOSP SERVICE: ER3 LGCATM: ER1- ACCP: 4242526 F —Firms Report— 1 EXAi1MINATION: CT ABD PEL W CONTRAST 182 –Feb 9 2011 i i COMMENTS: Exam:CT of the abdomen and pelvis with contrast, Mis#ory.Trauma. # Findings Serer axial CT images of the abdomen and pelvis were obtained*bowing the intravenous administration of 50 mi of isovue-370. Date was reconstructed In the ssgW and coronal planes. No ofa i conlrost was given. The Hoer, gallbladder, splaw, kidnays. adrenal glands, and pancreas are rwr4d. There is no evidence of free air. Bowel loops we normal. The superior mesenteric, splenic,and portal veins are patent. The hepatic veins are patent. The abdominal aorta w normal. Examination of the peA4e demonsbal es that the bladder. uterus, and adnexal structures are unrWroiable. There is no pelft free fluid. Examination of the osswus structures demonstrates that the osseous struckm are skeletally immature. No fracture is seen. Examination of the king bases demonstrMes some minimal atelectesis,in the right middle lobe. There is no pleural or pericardial effcteiar►. CONCLUSION: Normal CT of the abdomen and pelvis with contrast. WTATED BY! BRIAN MCINROY MD! DATE OF EXAM: Feb 9 2011 SID BY: t?#tIAN MCINROY MD DATEfTNE: Feb 9 2011 8:25P COWIDEMTW,This raport contains pdvade patient Worrnadon.If you have raoeivad this naW In aeon,pivaw case 7IT-9724%1 immadlstely. Confident aft Dbdsinaer.The Ndwmation mnWrwd M this communloom may be wdkfantial,is kftnded for the wo of the avow reaped above,and may ore lagW phlop .E Mate reader or lhds twonamp l a not tits intended redplerak you are hareb y raerMad lhard any ddwaardaltrtiaMa,�sra,a aaopyirrg d tithe oommunNafta.or any of W coat rft Is sMcdy prahbW.d you reoslved this enannmica*w in anon,please reesrraf We oomnrianieatian to the veradaar and dakft the WOW message and any copy of h from your awwular sydem.Thank You. hnegMg Sw0m Consultidon Page d Holy Spirit Hospital [epammmt of Radlolm and Diiagnoadc Imaging Camp Hill, Ponnsylvania 17011 (717)9724M PATIENT: WARSAME, ADINA A DICTATION DATE: Feb 9 2011 8:3OP MR#v* 667486 TRANSCRIP1M DATE:Feb 9 2011 8:25P PT CLASS: E ADW. 390=74 ORD O1R: SUSAN DACOSTA CRNP ADM DATE: 02109/2011 PT TYPE: E ARRIVAL DATE: DOB: OW=004 H©SP SERVICE: ER1 LOCATION: ER1- ACC>)E: 4242526 ' rj I-Im ER: F I � 1 Mudy inmweimtion provided by Qwu*=bisaeft To Provide We bat am n6d padiNnt was:Dwft routine da Orne Qaantum waakdat,wed end and hapday on4ft orrtrsrapa,s Qtlwantw RaftlogM can be cc hsv1sd at 717?1&4 iH{liaty 9W IMAGING Hose ftQ. l ftm@tiv*,a Q wdum RWio"W can be INOMd by otom 24 hours s day,awn days a weak at 7174 - W30. COMlKW TUL:This report owftns private patient Awmation. If you have received this report in error,piesee cab 717.272.4941 iirrmedGMeiy. GoeNfderiMby Declaimer The irdamwtion awAsined in this comma Resort maybe confidential.is' Is do for the use of the coh , named above,and may be Mpr I I'l p I If**rawer 0f this message Is not the I-a a dd d nrmipiart,you am hereby naW *4 any di esmineMan;dislobaftm or oopyirp of ft co xarbstlan,or any d ils con 1 1 .is strictly proiWiMad.if you rsoskeed this ow!trr unksaiion in error,pbsto n ewid this commutdcabon to the sender and 1 1 1s the odonst nlas— and any copy of N* nn your computer sya w.Thank You. WAqhq>3e vkft cOtaiitlllt IkM Pape 2 GENITAL __perineal hernatoma MAYS •`nml genital exam blood at urethral meatus Ole _nml vaginal exam _� XRA YS Qlnurp.by me- �viwed by me d _ _ M_ w/radblogkt Kdiagrom _, C-Spine T-Spine LS SOW { non-tender vertebral point-tenderness. - _nml J NAD _reversal/straightening of eery.lordosis_ _CVA tenderness _no fracture —DAD/spondylosis/spuMnR, e spasm nrnl alignment _fracture Hoer disptOted diepiaced W diagram _so$tissues rent y_ry�color �b/ hallo /laceration _ _ .— �w dry —cyanosis/d' s 1 pallor CXR rib fracture . n Inntt rash mi/NAD `inflaate!ateleccasb EXTREgMT{E,S _no infiltrates he t size �fJ'am--�- � Heal heart site ,Lmova all'Men itia Hulse deficit le —nml mediasti _non-tender _painful -beerin�--au" ml ROM* carnnot bear vwi� - OTHER Q o poise debdts _joint swelbna Magram IN"I PELVIS Time unchanged improved re-examined ./D,WO stable _bony poi tenderness eetaWM(nail fsr age) active pWW nail moW tone/activity %hips non-tender _pakhfirl/unable to bear weight_ Jetherlic aft ftwy ,amain on hip movemahe_ ,initial fracture cue provided: follow-up on , . 1 ❑Child Welfare NotNed ❑History confirmed in ado interview —Discussed wkh Dr. wilt see beams ft_ofroe/ED/hospkd............ ---- �� ' � Courereled Additional history m: story fro ; I Al y ; lad/ dtogrhods need for f f i+ cortredw paramedics f _RX�n ; C 11W bitable p^°cedees) PROGEDUMS' WOt11tdL------oltlRfpaU ----------------------- _30.74nin -_75-104m/n earn----_---- , bngP care location ; MVA FALL X*er&W +subcut. 'muscle linear stellate lnvguuhr I �i�'/�'� R 1 L sprain/strain t dean eor� modwoe*11heorlty � eN6ow R/L neck thoracic lumbar 411118W MYr: neuro A vascular scams intact no tendon ho ry forearm R/L anOGUM111111111: local d W block mL ; � wrist R/L _ Ndoc 1% 2% epl/b1carb maresine 015% 0.5% LET ; head hand R/L concussion ee Q moderate sededon r"Wred;s attached 113d template hip R/L with LOC w/o LOC prep: �ce thigh R/L BeUmMe/normW saline d' knee R/L laceration irrigated/washed vv/seine debrided leg R!L minarw!/read/*eirtemhv mininrd/ *mod ^exteruive ankle R/L wound explored undermined ; shoulder R/L foot R/L ' foreign material ewnovW minunoi/mod/'exte mm po+tiel� cnrrrplstely wound margins revised edrweted / transte"Id e�MNr"/mod/•eaterstw mui4hM flaps aftned � T TqJ?Mw" le& no harem body Idesttltled ❑uneM^gd ❑imp [stabl. repilde': Wound dared witty wound odhesire/Dermabond/steer nps ; fir/tail SKIN- # -0 nylon/prokne/staples 1 ' _Rasidene I PA I NP's M"• reviewed,pedwit Interviewed and ammined. ethi on ; 1160111Y.pertinent HR is: * i owmpted nwdit simple noty=(h/v) ; f,Peraanal exam d patient reveals: ' SUBCU i-# -0 vicryl J chromic , Assessmenc�and plan reviewed with residwnc/rNdiwe1.tab and anci" ' irrbrrupted rteK+fag arnpk neettroa(h/v} ' awdles shoyr _ �'.'ay Liu_!"R'4hdiosma aotip_lat_re�!ir---------- ' I confirm tM _� CT SCAN Gfe 0 wig need: Please Meal cheat abdomen _normal 1 NAD fracture/hemorrhage...- R710 aimed are over et LAOS-- ---------------- -- - ---------- ; CtBC t Hama! except � 1pr+kim 2lr+�►e RTJ• esezered ten sit WBC a_ _Glut i emplate Complete ❑Additional T Sheet ❑Dictated Addendum R9C b� K BUN. 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Mail tear-oR coupon heloup wiM putt using the enefosed sNf-�dfissad Patient Name: Warsarne,Atli A 0.08 Stag Date: 06/10/11 Total New Charges: $7,708.06 Pays /A4ushnwrts: 0.00 Service Date(s): 0210!9/11 Account Balance: #7,708.00 Account Number: 3!069274 Please Pay This Amount: $7,708.00 OR Medical Record Number. 687486 Diacouf td AMM Of 68,801.80 N path on Ins. 1:AUTO INS Please call Customer Service at 717-763-2138 Ins. 2: GATEWAY HEALT to add or make dons to your InSurance Iris. 3: infama6on,or to make arrarrpbnent$for a Ins. 4: payment Man. If you are unatrie to make payment,please Carted the Flklaelalai CounseWs Office at(117)7634885 to dimes financial asshdanoe options. Please Mole: You'physkhm wi bit separafe/y for pr ion®/services. M&M Chad Payer To: Holy Split Hospital Pay only 39059274 #8,8611 AMA A 1 Awmw M x 212Tsrsssz ❑ ❑ ❑ [] CMeanl.w►17011 Cad AMRESS SERt1ICE RE@IIESTED Gott wr it w iOrwpO�i11MM11ap M1 ate. Y——amt M back. 'TIN CW2 No.k Io*iAd b P�VOW pldlnnd. k b low hd 3 dot,n" rwokarvwwM&and,MroardVwhw roarA ca"I'ld ,kisft+4ftk 00006759 001 0.53 Mw*wonrwfiordafVwcw1d..r fwarld wdw 39050274 LEYLA 8ANRIYE '1i11'M11M1J11'1'1 886 CUMERLAND POINTE CIR HOLY SPIRIT HOSPITAL MECHANICABURG PA 17055-5490 P.O. BOX 872183 PHILADELPHIA,PA 19182-2183 000039059274001000007708000010073500000001130001156200000655160 071020116 Previous Baianre: 0.00 Total New Charges: $7,708.00 Payments/Adjustments: 0.00 AtL Account Balance: 07,708.00 Please Pay This Amount: $7,705.00 OR "`°f�r6i� Discounted Amount of$6,551.80 if paid on or before 07M 0/2011 TAMS,Deb Descrfndon Amount 02/09/11 CAST OCL 6 48.00 02/09/11 VEMPUNICTIJRE 19.00 02/89/11 i+ETA"LIC PANEL,C 169.00 02/09/11 CIC,AUTO DIFF 115.00 02/09/11 RIGHT ANKLE 276.00 02/09/11 RIGHT FOOT 276.00 02/09/11 CT AID PEL M C CHIO 6,015.00 02/09/11 LEVEL III FC 605.00 02/09/11 APP OF SHORT LES SPLINT 185.00 02/09/11 CRUTCHES .00 w • N a �O Please use this space to make corrections to your address or insurance information. Name: Account No: Phone: Address: Business Phone: Employer:— __—_- Employer Address:— Insurance Company:_ _ Effective Date: Insurance Company Address: — -- _ —Phone:-- Insurance Policy or Contact No: -- Group No: Policy Holder's Name:— Phone: Policy Holder's Date of Birth i Policy Holder's Gender:QM []F Policy Holder's Social Security No:____ -- Patient's Relationship to Insured: El Self [] Spouse ❑ Child n Other_ _ DILLSBURG AMBULANCE C/O PROMED SERVICES, INC, 4 W. MAIN STREET EXHIBIT SHIREMANSTOWN. P'A 17011 1.866.676-6855 'w U� Patient Bill Page: 1 Printed: 03/03/11 06:64 LEYLA SAMRIYE 10: DM-M12 666 CUMBERLAND POINTE CIRCLE Mechanicsburg, PA 17055 0013: Podwit: WARSAME,ADWA A ID: 3811 Claim Number: 641101410iagnosis 1) 959.7 In$; 0102109-02/09/11 007 A04998H 1 A 700.00 1 700.00 0.00 0.00 700.00 700.00 Pmoedure: BLS EMERGENCY SERVICE Dde**I bftd: 02/16M 1 Over 60 02 02MO-C 9/11 007 A04266H 1 A 143.00 11 143,00 0,00 0.00 143.00 143.00 Prooedure: MILEAGE Orate first billed: 02/18/11 Over 60 LET US KNOW IF YOU HAVE AUTO INS,COVERAGE.IF NOT,SALANCE IS DUE. Petk"Totsls: $43.00 643.00 0.00 0.00 0.00 843.00 843.00 Told Amount Due ft Guarantor: 849.00 www DETACH HERE vwvw --- _......._...,_ _---------------- ......................... PLEASE MAKE Ch B PAYABLE TO OILLSSURG AMBULANCE Prft fq h NtwrNra a aaae ait�and mMl me bottom aeotlon for eaoh OW and inolude with popnW ......... Guar:SAMRIM IEYLA N:C—*a12 e:941 011 Pepe 1 Taal Due(aI pepee):e43.00 EXHIBIT oc ADINA WARSAME, a Minor COURT OF COMMON PLEAS OF by Ahmed Warsame, Guardian and CUMBERLAND COUNTY Leyla Warsame, Guardian Plaintiff/Petitioner ORPHAN'S COURT V. : WEST SHORE EVANGELICAL FREE Case No.: CHURCH Defendant/Respondent AFFIDAVIT I, Ahmed Warsame, am over the age of 18 and am competent to testify to the matters set forth herein: 1. I am the parent and natural guardian of Adina Warsame, a minor, who on February 9, 2011, was thrown from a vehicle owned by the West Shore Evangelical Free Church, and sustained injuries as a result. 2. That as a result of being thrown from the vehicle the minor, Adina Warsame, sustained injuries to her back,knee and right foot, 3. As a result of being thrown from the vehicle, costs of $8,551.00 in ambulance and hospital bills have been incurred. 4. The sum offered in settlement for Adina "Varsame, $15,000.00 is fair, reasonable and equitable, and it adequately compensates for the injuries sustained and expenses incurred. I, Ahmed Warsame, do hereby verify that the statements made in the foregoing Affidavit are true and correct to the best of my knowledge, information and belief. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. Ahmed Warsame EXHIBIT ADINA WARSAME, a Minor COURT OF COMMON PLEAS OF by Ahmed Warsame, Guardian and CUMBERLAND COUNTY Leyla Warsame, Guardian Plaintiff/Petitioner ORPHAN'S COURT V. WEST SHORE EVANGELICAL FREE Case No.: CHURCH Defendant/Respondent AFFIDAVIT I, Leyla Warsame, am over the age of 18 and am competent to testify to the matters set forth herein: 1. I am the parent and natural guardian of Adina Warsame, a minor, who on February 9, 2011, was thrown from a vehicle owned by the West Shore Evangelical Free Church, and sustained injuries as a result. 2. That as a result of being thrown from the vehicle the minor, Adina Warsame, sustained injuries to her back,knee and right foot, 3. As a result of being thrown from the vehicle, costs of$8,551.00 in ambulance and hospital bills have been incurred. 4. The sum offered in settlement for Adina Warsame, $15,000.00 is fair, reasonable and equitable, and it adequately compensates for the injuries sustained and expenses incurred. I, Leyla Warsame, do hereby verify that the statements made in the foregoing Affidavit are true and correct to the best of my knowledge, information and belief. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unworn falsification to authorities. Leyla '� � w PARENTS' RELEASE AND nwzH TITY j KWW ALL MEN BY THESE PRESENTS: EXHIBIT l That AM= WARSAME AND LEYLA Nom, individually and as parents and guardians of ADM WARSAME, a au.nor, (hereinafter "Releasors") for and in consideration of the total sum of FlyTMM T80uSAND DOLLARS ($15,000.00) , do hereby remise, release and forever discharge HEST SHORE EVANGELICAL FREE CHURCH and BROTSERNOOD MUTUAL INSURANCE COMANY (hereinafter Releasees) , together with their employees, servants, workman, agents, officers, directors, assigns, successors, heirs, executors, and administrators, insurers, representatives, attorneys, subsidiaries, affiliates, parent companies, shareholders and any other person, partnership firm, corporation or any other entities charged or chargeable with responsibility or liability, of and from all manner of liability, actions and causes of action, suits, debts, dues, accounts, bonds, covenants, contracts, agreements, judgments, claims and demands whatsoever in law or equity, and specifically, any and all alleged claims arising out of injuries to ADINA U R1tSAME in a motor vehicle accident which allegedly occurred on the premises of West Shore Evangelical Free Church in Mechanicsburg, Pennsylvania, on or about February 9, 2011 , and other person, partnership, corporation or other entity charged or chargeable against with the responsible or liability and their successors, heirs, executors, administrators, they ever had, now have, or which their heirs, executors, administrators, successors or assigns, or any of them, hereafter can, shall or may have, for or by reason of any cause, matter or thing whatsoever, from the beginning of the world to the date of these presents . We hereby declare and represent that the injuries sustained are permanent and progressive and that recovery therefrom is uncertain and indefinite, and in making this release and agreement it is understood and agreed that we rely wholly upon our own judgment, belief and knowledge of the nature, extent and duration of said injuries and that we have not been influenced to any extent by any representations or statements regarding said injuries made by the persons, firms, entities or corporations who are hereby released, or by any person representing them. It is further understood and agreed by Releasors that any liens for disability payments, medical bills, Medicare benefits or other subrogation claims are our sole responsibility, are not the responsibility of any party released, and the same shall be paid and discharged from the settlement proceeds. As part of YOST&TRETTA,LLP•TWO PENN CENTER PLAZA•SUITE 610•1500 JOHN F.KENNEDY BOULEVARD•PHILADELPHIA,PA 19102 the instant settlement, Releasors and Releasors' counsel have agreed to indemnify and hold Releasees and Yost & Tretta, LLP harmless from any and all liens, expenses of any type including Medicare, Medicaid, medical offsets, i.e. , including attorneys' fees. Releasors has been informed by her counsel and is aware of the meaning and effect of this indemnity provision and has executed this agreement with full knowledge thereof. The undersigned further agree to hold the Releasees and their counsel, Yost & Tretta, LLP, harmless from, and to defend and indemnify the Releasees against, any now pending or subsequently initiated suits, claims, judgments, costs or expenses of any kind, including attorney' s fees, contribution, and/or indemnification by any other person or organization (or for subrogation by an insurer of such person or organization) on account of judgment, assertion or settlement of any claim asserted by or on behalf of the undersigned or the undersigned' s relatives as a result of the injuries or damages allegedly sustained by the undersigned and arising out of the above described accident or occurrence. It is further understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that the payment shall not be construed as an admission of liability on the part of any of the persons, firms, entities or corporations released. We hereby declare and represent and it is expressly understood that this release and settlement agreement is intended to cover and does cover not only all now known losses and damages, but also any further losses and damages which arise from or are related to the above claims . This release contains the Entire Agreement between the parties hereto, and the terms of this release are contractual and not a mere recital. We further state that we have carefully read the foregoing release and know the contents thereof, and we sign the same as our own free act. 2 YOST&TRErTA,LLP-TWO PENN CENTER PLAZA•SUITE 610.1500 JOHN F KENNEDY BOULEVARD•PHILADELPHIA,PA 19102 i I IN W��I//TNESS WHEREOF, I have hereunto set my hand and seal the �.�1�day of •�., , in the year of our Lord two thousand . .lzv SIGNED, SEALED AND DELIVERED IN THE PRESENCE OF Witness tl:raa�e tom'!lv to _ Witness "yla ra W, I it V0 STATE OF P ss COUNTY OF �""-et On this t w ay Gkf �L 12, before me personally appeared iM ,0 1AAA-4 to me known to be thef person who executed th foregoing instrument, and acknowledged that they executed the same as their free act and deed. NOTA PUBLIC p NOr q� m CouN ` 3 YOST&TRETTA,LLP«TWO PENN CENTER PLAZA+SUITE 610+1500 JOHN F.KENNEDY BOULEVARD+PHILADELPHIA,PA 19102 IN THE ORPHAN'S COURT FOR CUMBERLAND COUNTY,PENNSYLVANIA ADINA WARSAME, a Minor by Ahmed Warsame, Guardian and Leyla Samriye, Guardian Case No.: J Plaintiff/Petitioner V. WEST SHORE EVANGELICAL FREE CHURCH : Defendant/Respondent ACCEPTANCE OF SERVICE I accept service of the Petition for Court Approval of Settlement or Compromise of Action Involving Minor on behalf of West Shore Evangelical Free Church, and certify that I am authorized to do so. Michael F. Kernoschak Yost&Tretta, LLP Two Penn Center Plaza, Suite 610 1500 John F. Kennedy Boulevard Philadelphia,Pennsylvania 19102 -ate C r"C > =-r Attorney/Authorized Agent for Defendant zZ <x cn o° y � � FILED-OFFICw OF THE PR0THQN6_Tf-,R Y ADINA WARSAME, a Minor 7013 APR 26 A 10• 26 By Ahmed Warsame, Guard�a�# Ph�tR SYLVA alb Leyla Samriye, Guardian, Plaintiff/Petitioner V. IN THE COURT OF COMMON PLEAS OF THE NINTH JUDICIAL DISTRICT WEST SHORE EVANGELICAL FREE CHURCH, 'DID Defendant/Respondent 2013-A417&CIVIL TERM IN RE: PETITION FOR COURT APPROVAL OF SETTLEMENT OR COMPROMISE OF ACTION INVOLVING MINOR ORDER OF COURT AND NOW, this J eday of April 2013, upon consideration of the Petition for Court Approval of Settlement or Compromise of Action Involving Minor, it is ORDERED and DIRECTED as follows: 1. Petitioner is authorized to enter into a settlement with Defendant in the amount of$15,000.00 on behalf of the minor, Adina Warsame; 2. Counsel fees in the amount of$3,750.00, and costs in the amount of $103.75 shall be distributed from the settlement proceeds to Rick M. Grams. Esq. and Sagal, Cassin, Filbert & Quasney, P.A.; 3. The remaining settlement proceeds in the amount of$11,146.25 shall be deposited into a restricted, FDIC insured savings account in the name of the minor child, not to be withdrawn until the minor attains the age of majority; 4. Any requests for withdrawal prior to the minor attaining the age of majority must be approved by this court, only after good cause for the requested withdrawal has been shown; 5. Proof of deposit shall be filed of record with this court within thirty (30) days from the date of this Order of Court. f CUUFZT; Thom s . Placey C.P.J. stribution: Rick M.Grams,Esq. « nuuU ADINA WARSAME, a Minor By Ahmed Warsame, Guardian and Leyla Samriye, Guardian, Plaintiff/Petitioner V. IN THE COURT OF COMMON PLEAS OF THE NINTH JUDICIAL DISTRICT WEST SHORE EVANGELICAL FREE CHURCH, Defend ant/Respondent 2013-02014 CIVIL TERM IN RE: PETITION FOR COURT APPROVAL OF SETTLEMENT OR COMPROMISE OF ACTION INVOLVING MINOR ORDER OF COURT AND NOW, this day of May 2013, upon consideration of Attorney Rick M. 2ec Grams' verbal request via telephone for an extension of time to file proof of deposit of the settlement funds, the request is GRANTED and proof of deposit shall be filed THIRTY (30) DAYS from the date of this Order of Court. BY THE COURT, Thomas A. Placey C.P.J. Distribution: Rick M. Grams, Esq. cn L4. AI CD F OFFICE OF THE PROTHONOTARY 2013 JUN 19 Pr I: 2 7 CUMBERLAND COUNTY IN THE COURfWMM"A PLEAS FOR CUMBERLAND COUNTY, PENNSYLVANIA AD1NA WARSAME, a Minor by Ahmed Warsame, Guardian and IN THE COURT OF COMMON PLEAS Leyla Samriye, Guardian OF THE NINTH JUDICIAL DISTRICT Plaintiff/Petitioner V. : WEST SHORE EVANGELICAL FREE 2013-02014 CIVIL TERM CHURCH Defendant/Respondent PROOF OF DEPOSIT OF SETTLEMENT FUNDS Plaintiff/Petitioner Adina Warsame, a Minor, by Ahmed Warsame and Leyla Samriye, Guardians, and by and through her;undersigned counsel, hereby files this Proof of Deposit of Settlement Funds, and in support thereof states as follows: 1. This Court,by way of Order of Court signed by the Honorable Thomas A. Placey on April 25, 2013, approved the Settlement or Compromise of the above captioned matter, involving Adina Warsame, a Minor, in the amount of$15,000.00. 2. The Order required settlement proceeds in the amount of $11,146.25 to be deposited into a restricted, FDIC insured savings account in the name of the minor child, not to be withdrawn until the minor attains the age of majority or pursuant to an order of this Court. 3. The Order further required proof of deposit to be filed with the Court within thirty days of the date of the Order. On May 24, 2013, Judge Placey, entered another order granting an additional thirty days to file proof of deposit. 4. As evidenced by the document attached hereto as Exhibit A, an account was established in the name of Adina A. Warsame, and a restriction of "NO .WITHDRAWS [sic] 1 WITHOUT COURT ORDER UNTIL MINOR REACHES AGE OF MAJORITY" was placed on the account. 5. On June 14, 2013, a deposit was made from the settlement proceeds into the Minor's savings account in the amount of$11,146.25, as evidenced by the copy of the deposit receipt attached hereto as Exhibit B. WHEREFORE, Plaintiff/Petitioner requests that this Honorable Court accept the foregoing as proof of deposit and proof of compliance with this Court's Orders of April 25, 2013, and May 24, 2013. Respectfully submitted, SAGAL,CASSIN,FILBERT&QUASNEY,P.A. Dated: June 14, 2013 Rik M. Gralms, Esquire Attorney I.D.No. 203076 600 Washington Avenue Suite 300 Towson, Maryland 21204 Phone: (410) 823-1881 Fax: (410) 823-8032 Email: r rams ,sagallaw.com 2 p a IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY, PENNSYLVANIA ADINA WARSAME, a Minor by Ahmed Warsame, Guardian and IN THE COURT OF COMMON PLEAS Leyla Samriye, Guardian OF THE NINTH JUDICIAL DISTRICT Plaintiff/Petitioner V. WEST SHORE EVANGELICAL FREE 2013-02014 CIVIL TERM CHURCH Defendant/Respondent CERTIFICATE OF SERVICE 1, Rick M. Grams, certify on this 17th day of June, 2013 that a true and correct copy of the enclosed Proof of Deposit has been served via first class mail, postage prepaid, upon the following: Richard W. Yost Michael F. Kenoschak Yost& Tretta, LLP Two Penn Center Plaza, Suite 610 1500 John F. Kennedy Boulevard Philadelphia, Pennsylvania 19102 Attorneys for Defendant 'Rick M. Gram 3 RINI- MAN i v ' Off� - e i ' RSHO 3 FSS PST !,AFC HG'i_.D INr.!MA'I tvT 13/06/14 15 . 19 . 36 RSMU vQ 96 OP EBRN IFIS 46677 ONLY ONE ITEM FOUND FOR SEARCH AC ION INQ coID, PROD COTE DDA P�.CCT 9276 SHOR°?' t+AME iWARSAME_ ADINA A CLASS . 1 i 1 . 2. TYPE ., 13 SELF 1 CURRENCY TYPE .'ODE . . . . . . . . DATE PLACED. . . . . . . . . . . 113/06/14 REASON CODE DATE EXPIRES . . . . . . . . . . . 999/99/99 STATUS CODE . . . . . . . . . . . 1 SPECIAL COMMENTS LTp�E 1 ENO WITHDRAWS WITHOUT COURT ORD` LTNE 2 ER UNTIL MINOR .REACHES THE- AGE.= RESTRAINT REASON LINE -1 ! OF MAJORITY L.I.NE 2 STATUS CODE VALUES 1 = A;;T I VE 2 = DELETE A = ACTIVE. }SAID D = DELEfr PAID PF : 2..CONT 4- CHG 5-FAD G- INQ 9-NX*T -DEL. -ADD _ a .r 00 . 1 03/009 i EXHIBIT - A a 8 M&TBank Understanding w iat importune Towson Office If you have any questions, please call our Telephone Banking Center at 1-800-724-2440 Today's Date: Business Date: 06/14/2013 06/17/2013 Time: 03:20 PM Savings Deposit $11,146.25 ****9276 6487/07 3 Thanks for visiting us today. We are happy to assist you! EXHIBIT a a f IN THE COURT OF COMMON PLEAS FOR CUMBERLAND COUNTY, PENNSYLVANIA ADINA WARSAME, a Minor by Ahmed Warsame, Guardian and IN THE COURT OF COMMON PLEAS Leyla Samriye, Guardian OF THE NINTH JUDICIAL DISTRICT Plaintiff/Petitioner V. WEST SHORE EVANGELICAL FREE 2013-02014 CIVIL TERM CHURCH Defendant/Respondent ORDER APPROVING COMRPOMISE, SETTLEMENT AND DISTRIBUTION AND NOW,this'day of ,2013, upon consideration of the Proof of Deposit ofSettlement Funds, it is ereby - ORDERED that the Plaintiff/Petitio rders of April 25, 2013, and May 24, 2013 Judge, Cumberl County Court of Common Pleas Distribution: Thomas A. Placey Common Pleas Judge Rick M. Grams, Esq. .Michael F. Kernoschak, Esq. `; - i=C w —I MM C—V O� ;-7 f ',-Z, --1 r°, ---s r�