ODF II Registration
All participating members will be required to bring paper copies of the noted forms. (CAPFs 60-81, 160, 161, 163)
Member's Name
*
First Name
Last Name
CAPF 60-81 Application for Encampment
Parent Email
*
Confirmation Email
example@example.com
Cadet Email
Confirmation Email
example@example.com
CAP ID Number
*
Example : 619863
Charter Number
*
SWR-AR-107
Current Rank
*
Please Select
C/Amn
C/A1C
C/SrA
C/SSgt
C/TSgt
C/MSgt
C/SMSgt
C/CMSgt
C/2d Lt
C/1t Lt
C/Capt
C/Maj
C/LtCol
C/Col
Senior Member
Gender
*
Please Select
Male
Female
Member Type
*
Please Select
Cadet Student
Cadet Staff
Senior Staff
Grade in school
*
Birthday
*
-
Month
-
Day
Year
Date
Height (Inches)
*
Weight (lbs)
*
Hair Color
*
Eye Color
*
Religious Preference
Adult T-Shirt Size
*
Please Select
X-Small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
XXXX-Large
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Phone Number
*
Please enter a valid phone number.
Parent Phone Number Confirm
*
Please enter a valid phone number.
Cadet Phone Number
Please enter a valid phone number.
Cadet Phone Number Confirm
Please enter a valid phone number.
Primary Contact Name (Last, First)
*
Primary Contact (Relationship to Cadet)
*
Example : Mother, Grandfather
Primary Contact Phone
*
Please enter a valid phone number.
Secondary Contact Name (Last, First)
*
Secondary Contact (Relationship to Cadet)
*
Example : Mother, Grandfather
Secondary Contact Phone
*
Please enter a valid phone number.
RELEASE AGREEMENTKNOW ALL MEN BY THESE PRESENTS
that I am submitting my application for Civil Air Patrol Special Activities or Encampments, and I hereby volunteer entirely upon my own initiative, risk, and responsibility for an assignment to participate in this activity of encampment at the first available opportunity and with full knowledge that such activity may include: 1. Traveling by land, sea, or air in US military, commercial, or privately owned vehicles from regular place or residence to the site of the activity or encampment, travel incident to the activity or encampment, and subsequent return to place of residence. 2. Participation in aeronautical activities as a passenger or student trainee in US military, commercial, or privately ownedaircraft.3. Living for a period of one week or more on diminished rations and minimal shelter simulating actual survival conditions. 4. Being quartered and/or subsisting away from regular or normal place of residence for an extended period of time. 5. Remaining with the cadet group I am assigned to at all times during the activity or encampment. 6. Acting as a spokesman for Civil Air Patrol, rendering reports on the activity or encampment. 7. Refraining from argumentative discussions concerning governmental 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 activity/encampment or activities/encampments, I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Civil Air Patrol, Inc./United States of America, and all its officers, agents, and employees acting official or otherwise, from any and all claims, demands, actions, or causes of action, 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 said activity/encampment or activities/encampments or continuances thereof, as well as all ground and flight operations incident thereto
Applicant's Signature
*
Father's Signature
*
Mother's Signature
*
CAPF 160 CAP Member Health History Form
Allergies
List Names of Medication or Other Allergies (i.e., bee sting, food, plants) and typesof reactions; please note food allergy details with dietary restrictions below
Do You Now Have Or Have You Ever Had Any Of The Following?
Explain any yes’ in the remarks section below. (Conditions not specifically noted below having the potential to interfere with performance during the special activity or encampment should be documented in the remarks section.)
*
Yes
No
Decreased vision, glaucoma, contacts
Ear infections, perforation
Difficulty equalizing ears
Hearing loss, hearing aid
Allergies, nasal stuffiness
Anaphylaxis, serious allergic reaction
Asthma, emphysema (COPD)
Ever use an inhaler
Short of Breath with activity
Heart Attack, chest pain, angina
Heart murmur, heart problems
Congestive heart failure
Irregular or rapid heartbeat
High or low blood pressure
Stomach trouble, ulcers
Hepatitis or liver problems
Diarrhea, constipation
Hernia or rupture
Kidney disease or stones
Prostate problems (men)
Frequent urination
Menstrual cramps (women)
Broken bone, joint problems
Chronic or recurring injuries
Activity, mobility restrictions
Use of cane, walker, wheelchair
Back or neck pain or injury
Migraine or severe headaches
Dizziness or fainting spells
Head injury, unconsciousness
Epilepsy or seizure
Stroke, paralysis
Thyroid problems (low or high)
Diabetes, high or low blood sugars
Cancer, leukemia
Blood disease, hemophilia
Motion sickness
Special diet, food allergies
Current bedwetting problems
ADD (Attention Deficit Disorder)
Mental illness (bipolar, other)
Depression, anxiety, suicidal
Admission to the hospital
Other chronic medical illnesses
Sleep disorder, sleep apnea
Serious Injury
Remarks
Dietary Restrictions or Limitations
(List any dietary restrictions like food allergies, diabetes, gluten-free, vegetarian diets, etc.)
Past Surgical History
(List all surgeries including tonsils, ear tubes, appendix, gall bladder,hernia, hysterectomy, heart, heart catheterization, bone and joint and all other surgeries.)
Date Tetanus Booster
-
Month
-
Day
Year
If none, leave blank
If you have had the Tetanus Booster, what variation did you receive?
Please Select
Td
Tdap
Date Hepatitis Vaccine
-
Month
-
Day
Year
If none, leave blank
Date Pneumonia Vaccine
-
Month
-
Day
Year
If none, leave blank
Date Varicella Immunization/chickenpox
-
Month
-
Day
Year
If none, leave blank
Date Influenza Vaccine
-
Month
-
Day
Year
If none, leave blank
Tobacco Use
*
(packs per day, years smoked, smokeless tobacco use. If none, type 'none')
Occupation
*
(Student or other)
Medication Information : Include supplements, over-the-counter medicines, herbals, creams, etc. If not on medication, type "none"
Name of Medication
Tablet Strength
Times taken per day
Reason for medication
Special Dosing / Storage
1st Med
2nd Med
3rd Med
4th Med
Remarks
CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT
I give permission for full participation in CAP programs, subject to any limitations noted herein.My signature below evidences my consent for my child/ward to possess and self-administer the prescriptionmedications listed above I understand that there are legal limitations imposed on CAP senior members withregard to the involuntary administration of medications to my child/ward. (Cross out if permission is denied).In case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached, Ihereby give my permission to the licensed health-care practitioner selected by the adult leader in charge to secureproper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medicalproviders are authorized to disclose to the adult in charge exam/test results and treatment provided.
Parent/Guardian Signature
*
CAPF 163 Permission for Provisions of Minor Cadet Over-the-Counter Medication
Over-The Counter/Non-Prescription Medications
The following over-the counter medications may be administered according to packagedirections by CAP senior members. Cross out any medications not approved.
Select 'No' for any medication not approved.
*
Yes
No
Acetaminophen (Tylenol) for fever or pain
Ibuprofen (Advil, Motrin) for fever or pain
Bacitracin or Neosporin antibiotic ointment to
prevent infection
Hydrocortisone anti-inflammatory rash cream
Calamine/Caladryl for poison ivy itch relief
Antifungal creams and sprays for treatment of
fungal rashes
Visine eye drops for dry, irritated eye relief
Op-Con A eye drops for allergic conjunctivitis
Benadryl liquid/tabs for allergic reactions
Claritin antihistamine for seasonal allergies
Robitussin products for relief of cough and
cold symptoms
Delsym to suppress cough
Tums or Maalox for relief of stomach upset
Allergies
My child/ward has the following allergies or reactions to over-the-counter medications (list typeof reaction):
Consent For Minor Cadet To Receive Over-The-Counter Medications
My signature below evidences my consent for CAP senior members to provide over-the-counter non-prescription medications (such as those listed above) to my child/ward if indicated in the reasonable judgment of such senior members. I understand that I will be informed if any such medications are administered.
Signature of Parent/Guardian
*
Base Access Information
Security Forces Squadron Visitor’s Center Access
For all persons, cadets included, over 18 who will be needing access to Camp Robinson. The base will be running background checks on Driver License Numbers. Those with suspended licenses will not be able to gain access to the base.
Adult/Parent Name
*
First Name
Last Name
Driver’s License / State ID Number
*
DOB
*
-
Month
-
Day
Year
Date
Last 4 Social Security Numbers
*
Notes (concealed handgun permit, suspended license etc.) For SFS USE ONLY
2nd Adult/Parent Name
First Name
Last Name
Driver’s License / State ID Number
DOB
-
Month
-
Day
Year
Date
Last 4 Social Security Numbers
Notes (concealed handgun permit, suspended license etc.) For SFS USE ONLY
VERIFICATION
I verify that the information listed on this form is both correct, accurate, and true to the best of my knowledge.
Yes
No
Submit
Should be Empty: