ÐÏà¡±á>þÿ :<þÿÿÿ789ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Áq` ù¿ËbjbjqPqP .::î8Kÿÿÿÿÿÿ¤xxxxxxxŒôSôSôS8,TìU,Œ½‚öPWÒ"_"_"_"_"_|žb¢d¸ºººººº$³ƒh†°Þ™xôi"_"_ôiôiÞxx"_"_w‚ünününôipx"_x"_¸ünôi¸ünün:Ps,xxØs"_DW 4‚©ÇôSdj¬|s ,tŒ ‚0½‚†sRË†k”Ë†ØsË†xØsT¦eÄfÌüng¤4hÀ¦e¦e¦eÞÞ¤nX¦e¦e¦e½‚ôiôiôiôiŒŒŒäMpR„ŒŒŒpRŒŒŒxxxxxxÿÿÿÿAPPLICATION FOR CONNECTICUT WING ENCAMPMENTFILL IN THE FOLLOWING PAGESCOMPLETELY.NAME (Last Name, First Name, Middle Initial) FORMTEXT FORMTEXT FORMTEXT JOINED CAP (MM YY) FORMTEXT FORMTEXT ACTIVITY YOU WISH TO ATTEND (PLEASE CHECK)CAPID FORMTEXT SOCIAL SECURITY # FORMTEXT CAP GRADE FORMTEXT UNIT CHARTER NUMBER FORMTEXT REGION FORMTEXT WING FORMTEXT MAILING ADDRESS (Number and Street) FORMTEXT FORMTEXT BASIC ENCAMPMENT CADET CADET STAFF SENIOR STAFF LEADERSHIP ACADEMY CADET CADET STAFF FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX (City) FORMTEXT (State) FORMTEXT (ZIP Code) FORMTEXT DATE OF BIRTH (MM DD YY) FORMTEXT FORMTEXT FORMTEXT HEIGHT FORMTEXT WEIGHT FORMTEXT GENDER FORMTEXT HAIR COLOR FORMTEXT EYE COLOR FORMTEXT RELIGIOUS PREFERENCE FORMTEXT PRESENT OCCUPATION FORMTEXT E-MAIL ADDRESS FORMTEXT HOME PHONE FORMTEXT BUSINESS/ALTERNATE FORMTEXT FAX FORMTEXT The entries in these fields MUST appear legibly, or this form will be returned SENIOR STAFF FORMCHECKBOX Memorandum Of Understanding On Performance and Absences I agree and understand that I am attending Connecticut Wing Encampment of my own free will and am expected to perform my duties as a student, cadet leader, senior leader, cadet support staff member, or senior support staff member in a satisfactory manner in accordance with Civil Air Patrol Regulations and under the lawful orders and directives of the Connecticut Encampment Commander and staff. I understand and agree that the Encampment Commander may direct me to leave the Encampment at any time if my performance is not satisfactory or if I fail to follow lawful orders or directives. I further agree that I will not leave The Connecticut Wing Encampment unless authorized or directed to do so by the Encampment Commander or designated legal representative. If I am the parent or legal guardian of a cadet attending Connecticut Wing Encampment, I agree that the Connecticut Wing Encampment Commander or representative will contact me and I will provide transportation for my cadet should he/she be directed or authorized to leave Encampment and I further agree and understand that my cadet cannot leave Encampment unless authorized to do so. I also agree to hold: 1. National Headquarters, Civil Air Patrol; 2. Connecticut Wing Headquarters, Civil Air Patrol; and 3. The Connecticut Wing Encampment Commander and staff harmless, for any actions taken in conjunction with the above, whether I am a parent/legal guardian or Civil Air Patrol member.Signature of CAP Member (cadet or senior) Signature of Parent or Legal Guardian FORMTEXT FORMTEXT FORMTEXT Printed Name and Rank of Member Printed Name or Parent or Legal Guardian FORMTEXT FORMTEXT Daytime Phone NumberEvening Phone NumberAlternate contact in event parent is unavailable NAME FORMTEXT DAYTIME PHONE NUMBER FORMTEXT EVENING PHONE NUMBER FORMTEXT RELEASE AND HOLD HARMLESS This application is being submitted for the Civil Air Patrol Connecticut Wing Encampment to be conducted at the Connecticut Army National Guard Facilities located at Camp Rell, Niantic, Connecticut (the “Encampment”). This application is being made entirely upon my own or our and my child’s own initiative, risk and responsibility to participate in the training at the first available opportunity and with full knowledge that the Encampment may include: Traveling by land, sea or air in U.S. Military, commercial or privately owned vehicles from regular place of residence to the site of the Encampment, travel incident to the Encampment and subsequent return to place of residence; Participation is a wide variety of physical activities; Participation in aeronautical activities as a passenger or student trainee in U.S. Military, commercial or privately owned aircraft; Living for a period of one week or more on diminished rations and minimal shelter simulating actual survival conditions; Being quartered and/or subsisting away from regular or normal place of residence for an extended period of time; Remaining with the cadet group assigned to at all times during the Encampment; Acting as a spokesperson for Civil Air Patrol, rendering reports on the Encampment, which may include, without limitation, being interviewed by the news media; Refraining from argumentative discussions concerning lawful orders and/or government policies. In consideration for the permission extended to me/us whereby my child or myself, ___________________ (the “Participant”) is about to participate in the Encampment, the Participant is doing so entirely upon his or her own initiative, risk and responsibility; and with full knowledge, consent and approval by me as the Participant or Participant’s (Parents/Legal Guardian). In consideration for the permission extended to me (participant) or my child (participant) by the Civil Air Patrol, Inc., the United States of America, the State of Connecticut, the Connecticut Army National Guard, and the Civil Air Patrol – Connecticut Wing, through its members, officers, agents, employees acting officials or otherwise to participate in the Encampment, to the fullest extent allowed by law, I do hereby for myself, my child, my heirs, executors, administrators and assigns, release and forever discharge the Civil Air Patrol, Inc., the United States of America, the State of Connecticut, the Connecticut Army National Guard and the Civil Air Patrol – Connecticut Wing, its members, officers, agents, employees, acting officials or otherwise, from and against any and all claims, demands, actions, causes of actions on account of death or bodily injury of any kind or nature to myself or my child(ren) which may occur as a result of the Training whether or not such bodily injury or death is caused in whole or in part by the active or passive negligence of the Civil Air Patrol, Inc., the United States of America, the State of Connecticut, the Connecticut Army National Guard, and the Civil Air Patrol – Connecticut Wing, its members, officers, agents, employees, acting officials or otherwise. Further, to the fullest extent permitted by law, I do hereby for myself, my child, my heirs, executors, administrators and assigns agree to defend, indemnify and save harmless the Civil Air Patrol, Inc., the United States of America, the State of Connecticut, the Connecticut Army National Guard, and the Civil Air Patrol – Connecticut Wing, its members, officers, agents, employees, acting officials and otherwise from and against any and all claims, losses, expenses (including attorneys’ fees), demands, actions, causes of actions arising out of or resulting from the Training, provided that such claim, damage, loss or expense is attributable to bodily injury, sickness, disease or death, or to injury or destruction of tangible property, but only to the extent caused by the negligent acts or omissions of the Participant or me or anyone for whom the Participant or I may be liable regardless of whether or not such claim, damage, loss or expense, is caused in whole or in part by a person or entity indemnified hereunder. Further, I understand that the news media may be invited to view, photograph or film portions of the Encampment, and to interview Participants. I agree and consent to the use of my own or my child’s (participant’s) photograph, image, quote or voice in news presentations. I/we further represent and warrant the following: If the Participant is a child, that the Participant is my child or legal ward; That the Participant has no history of injury or disease which might be affected by the Encampment, except those disclosed in the medical information section of this form; That the Participant will follow all lawful orders, rules, regulations and directives as established by the Encampment Commander, or other staff members. In the event the Participant refuses to follow the aforementioned lawful orders, rules, regulations and directives, the Participant may be sent home at the discretion of the Encampment Commander at my/our sole cost and expense. Further, in the case of injury, disease or other illness, permission is hereby granted to treat the Participant as required, and if the Participant is released from the Encampment before the recovery of said injury, disease or illness, further treatment will be provided by myself. ________ ________________________ ______________________________ Date Witness Participant, Father or Legal Guardian _________ _________________________ _______________________________ Date Witness Mother or Legal Guardian Medical information - to be completed by all applicants This information is for Official Use Only and Will not be released to unauthorized persons. Answer all questions as accurately as possible so that encampment staff can make themselves aware of any pre-existing medical problems or conditions and be alert to help you.DO YOU CURRENTLY USE ANY MEDICATION? (Including eye drops) FORMCHECKBOX NO FORMCHECKBOX YES (List any medications taken and the reason in the remarks section.)HAVE YOU HAD OR BEEN INVOLVED IN AN ACCIDENT IN THE PAST 2 YEARS? FORMCHECKBOX NO FORMCHECKBOX YES (Explain the extent of your injuries & treatment in the remarks section) HAVE YOU HAD OR HAVE YOU NOW ANY OF THE FOLLOWING (If yes is answered on any item, please explain why in the remarks section with the dates and physician(s) consulted (if any). Items not specifically noted below having potential to interfere with performance during encampment should be documented in the remarks section.) FORMCHECKBOX NO FORMCHECKBOX YESFrequent or severe headaches FORMCHECKBOX NO FORMCHECKBOX YESEar infection FORMCHECKBOX NO FORMCHECKBOX YESChronic diseases like diabetes or bronchitis FORMCHECKBOX NO FORMCHECKBOX YESDizziness or fainting spells FORMCHECKBOX NO FORMCHECKBOX YESRupture FORMCHECKBOX NO FORMCHECKBOX YESGirls Only - Menstrual cramps FORMCHECKBOX NO FORMCHECKBOX YESUnconsciousness for any reason FORMCHECKBOX NO FORMCHECKBOX YESPositive TB skin test FORMCHECKBOX NO FORMCHECKBOX YESOther illness or accidents FORMCHECKBOX NO FORMCHECKBOX YESEye trouble, excluding glasses FORMCHECKBOX NO FORMCHECKBOX YESEpilepsy or fits FORMCHECKBOX NO FORMCHECKBOX YESMilitary rejection or medical discharge FORMCHECKBOX NO FORMCHECKBOX YESHay fever FORMCHECKBOX NO FORMCHECKBOX YESKidney stones or blood urine FORMCHECKBOX NO FORMCHECKBOX YESRejection for life insurance FORMCHECKBOX NO FORMCHECKBOX YESSugar or albumin in urine FORMCHECKBOX NO FORMCHECKBOX YESMotion sickness FORMCHECKBOX NO FORMCHECKBOX YESAdmission to hospital FORMCHECKBOX NO FORMCHECKBOX YESHeart trouble FORMCHECKBOX NO FORMCHECKBOX YESNervous trouble of any sort FORMCHECKBOX NO FORMCHECKBOX YESRecord of traffic convictions FORMCHECKBOX NO FORMCHECKBOX YESHigh or low blood pressure FORMCHECKBOX NO FORMCHECKBOX YESAny known allergies FORMCHECKBOX NO FORMCHECKBOX YESRecord of other convictions FORMCHECKBOX NO FORMCHECKBOX YESStomach trouble FORMCHECKBOX NO FORMCHECKBOX YESAny drug or narcotic habit FORMCHECKBOX NO FORMCHECKBOX YESAttempted suicide FORMCHECKBOX NO FORMCHECKBOX YESAsthma FORMCHECKBOX NO FORMCHECKBOX YESChronic or recurring injuries FORMCHECKBOX NO FORMCHECKBOX YESMedical treatment within the past 5 years other than regular office visits or physicalsIMMUNIZATIONS FORMTEXT XZ¤¨ª * , 0 2 F H J T V Z \ p r t x z | ¤ ¦ º ¼ ¾ Ä Æ È Ê Þ øôîèîôîØÍºØ¥ØÍØÍ’Ø¥ØÍØÍØ¥ØÍîØÍlØ¥ØÍØÍ$jvhI;]5CJOJQJU$jhI;]5CJOJQJU$jŽhI;]5CJOJQJU)jhÆ>Û5CJOJQJUmHnHu$jhI;]5CJOJQJUhI;]5CJOJQJjhI;]5CJOJQJU hð[œCJ hI;]CJ hI;] hI;]5CJ&XZ¨ª ö™ö<66$If\kd$$If–l4ÖÖZL,€ò+Ö0ÿÿÿÿÿÿöÖÿÖÿÖÿÖÿ4Ö laöÆf4\kd$$If–l4ÖÖZL,€ò+Ö0ÿÿÿÿÿÿöÖÿÖÿÖÿÖÿ4Ö laöÆf4 $$Ifa$|ÊËþþ | ¢ ¤ ì î & ( F H T V ùùùððððððmùù‚kd`$$If–l4ÖÖFZ4¤L,Úp`¨ÿÿÿÿÖ0ÿÿÿÿÿÿöÖÿÿÿÖÿÿÿÖÿÿÿÿÿÿÖÿÿÿ4Ö laöÆf4 $$Ifa$$IfÞ à â è ê ì î & ( F H R V X l n p z | ~ ¤ ¦ º ¼ ¾ È Ê Ì â ä ø ú ü 4íÝÈÝ½¶¯¶©¥Ÿ™Ý½†ÝÈÝ½Ÿ™Ý½sÝÈÝ½™Ý½`ÝÈÝ½™$jhI;]5CJOJQJU$jœhI;]5CJOJQJU$j&hI;]5CJOJQJU hI;]CJ hÆ>ÛCJ hI;] hI;]CJ hI;]5CJ hI;]5CJhI;]5CJOJQJ)jhÆ>Û5CJOJQJUmHnHujhI;]5CJOJQJU$jêhI;]5CJOJQJU%V ~ ¢ ¤ Ì à â 24\jl”ž ÄÆöðööððöððöððöððöð$If $$Ifa$46JLNXZ\ln‚„†’” ¢¶¸ºÀÂÄÈ(*,68:<PRT^`bðåÒð½ðå·ðå¤ð½ðå·ðå‘ð½ðå·ðåzð½ðåðågð½ðå$j‚hI;]5CJOJQJU$jhI;]5CJOJQJUhI;]$jthI;]5CJOJQJU$jþhI;]5CJOJQJU hI;]CJ )jhÆ>Û5CJOJQJUmHnHu$jˆhI;]5CJOJQJUhI;]5CJOJQJjhI;]5CJOJQJU'ÆÈb.((($IfÐkdê$$If–l4Ö”?ÖžZF@,4´¤L,ìúì€ð ¨ÿÿÿÿÖ0ÿÿÿÿÿÿöÖÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿÿÿÿÖÿÿÿÿÿÿÿ4Ö laöÆf4bd’²´àâ F H h j – ˜ š œ ž Â Ä è ê ùùùùùùùùùùùùùùùùùððððððððððð $$Ifa$$IfbF H h j ” – ˜ ž ¼ ¾ À Ä Æ â ä æ ê ì 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If YES, explain FORMTEXT T-Shirt Size FORMCHECKBOX XS FORMCHECKBOX s FORMCHECKBOX m FORMCHECKBOX l FORMCHECKBOX xl FORMCHECKBOX xxl FORMCHECKBOX xxx SQUADRON CERTIFICATIONI certify that the above information is correct and that all the requirements for attendance, as specified in National Headquarters and/or Connecticut Wing Headquarters Directives, will be completed by the required dates. This applicant is applying forBasic EncampmentCadetLeadership AcademyCadetCadet StaffCadet StaffSenior StaffSenior StaffSQUADRON COMMANDEROUT OF STATE WING CERTIFICATIONI certify that the above information is correct and that all the requirements for attendance, as specified in National Headquarters and/or Connecticut Wing Headquarters Directives, will be completed by the required dates. 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