ࡱ> Z`\[vDText55vDText59vDText56vDeCheck13vDeCheck15vDText57vDeCheck14vDeCheck16vDAPPLICATION FOR CONNECTICUT WING ENCAMPMENTFILL IN THE FOLLOWING PAGES AS ACCURATELY AND COMPLETELY AS POSSIBLE. PLEASE TYPE OR PRINT NEATLY. IF FORMS ARE NOT LEGIBLE THEN YOU MAY NOT BE SELECTED FOR THE ENCAMPMENT.NAME (Last Name, First Name, Middle Initial)  FORMTEXT        FORMTEXT        FORMTEXT   JOINED CAP (MM YY)  FORMTEXT      FORMTEXT     ACTIVITY YOU WISH TO ATTEND (PLEASE CHECK) CAPSN  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 SENIOR STAFF  FORMCHECKBOX   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       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 Number CTWG Form 31-A (1/01) 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      FAMILY PHYSICIAN (Name, address, and phone number)  FORMTEXT      INSURANCE INFORMATION FORMCHECKBOX  Medical Company FORMTEXT       FORMCHECKBOX  Liability Company FORMTEXT      Policy Number FORMTEXT      Policy Number FORMTEXT      EMERGENCY ADDRESS - PARENT, GUARDIAN, OR CLOSEST RELATIVE TO BE NOTIFIED IN CASE OF EMERGENCYName FORMTEXT      Address FORMTEXT        FORMTEXT      Relationship FORMTEXT      Daytime Phone( FORMTEXT    )  FORMTEXT    - FORMTEXT     Nighttime Phone( FORMTEXT    )  FORMTEXT    - FORMTEXT     REMARKS  FORMTEXT       RELEASE AGREEMENTKNOW ALL MEN BY THESE PRESENTS that I am submitting my application for Connecticut Wing Encampment, and I hereby volunteer entirely upon my own initiative, risk, and responsibility to participate in this activity of encampment at the first available opportunity and with full knowledge that such activity may include: 1. 2. 3. 4. 5. 6. 7.Traveling by land, sea, or air in US 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 in aeronautical activities as a passenger or student trainee in US 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 I am assigned to at all times during the encampment. Acting as a spokesman for Civil Air Patrol, rendering reports on the encampment. Refraining from argumentative discussions concerning government policies.In consideration of the permission extended to me by the Civil Air Patrol/United States of America through its officers and agents to participate in said encampment, I do hereby for myself, my heirs, executors, and administrators release and forever discharge Civil Air Patrol, Inc/United States of America, and all of its officers, agents and employees acting official or otherwise, from any and all claims, demands, actions, or causes of actions, on account of my death or on account of any injury to me or my property which may occur as a result of the negligence of the Civil Air Patrol/United States of America, its agents or employees during the encampment or continuances thereof, as well as all ground and flight operations incident thereto. FORMTEXT      DATESIGNATURE OF APPLICANTRELEASE BY PARENTS OR GUARDIANS KNOW ALL MEN BY THESE PRESENTS: WHEREBY my child has applied for encampment referred to above, In consideration of the permissions extended to my child by the Civil Air Patrol/United States of America through its officers and agents to participate in encampment, I do hereby for myself, my heirs, and administrators release and forever discharge the Civil Air Patrol, Inc/United States of America, and all of its officers, agents and employees acting official or otherwise from all claims, demands, actions or causes of action, on account of my child's death or on account of any injury to my child or my child's property which may occur as a result of the negligence of the Civil Air Patrol/United States of America, its agents or employees during the encampment of continuances thereof, as well as all ground and flight operations incident thereto. In addition, by my signature below, I certify that the applicant: 1. 2. 3.Is my child or ward. Has no history of injury or disease which might be affected by this activity except those previously noted in the Medical Information section of this form. Will follow all rules, regulations, and directives as established by Civil Air Patrol, Inc., encampment commander, or other staff members. If not following the above mentioned rules, regulations, and directives he/she may be sent home at the discretion of the encampment commander at my expense. However, in case of injury, disease or other illness, permission is hereby granted to treat the applicant as required, and if the applicant is released from the encampment before recovery from said injury, disease, or illness, further treatment will be provided by myself. FORMTEXT      DATEWITNESS FOR FATHER'S SIGNATUREFATHER OR LEGAL GUARDIANWITNESS FOR MOTHER'S SIGNATUREMOTHER OR LEGAL GUARDIANSQUADRON CERTIFICATIONI certify that the above information is correct and that all the requirements for attendance, as specified in National Headquarters Directives, will be completed by the required dates. This applicant is applying forBasic EncampmentCadetLeadership AcademyCadetCadet StaffCadet StaffSenior StaffSenior StaffSQUADRON COMMANDERWING CERTIFICATIONI certify that the above information is correct and that all the requirements for attendance, as specified in National Headquarters Directives, will be completed by the required dates. This applicant is applying forBasic EncampmentCadetLeadership AcademyCadetCadet StaffCadet StaffSenior StaffSenior StaffWING COMMANDERAPPLICATION CHECKLIST FORMCHECKBOX APPLICATION IS FILLED OUT COMPLETELY AND LEGIBLY, AND HAS ALL SUPPORTING DOCUMENTATION ATTACHED. 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