, the parent/legal guardian of

, a member of the MCJROTC, in consideration of his/her membership in the program, do hereby release from any and all claims, demands, actions, or causes of action, due to death, injury, or illness, the government of the United States and all its officers, representatives, and agents acting officially and also the local, regional and national Marine Corps officials of the United States.

I hereby authorize personnel of the Department of Defense, Armed Forces, Public Health Service or civilian physicians to render such medical and dental care as may be necessary and medically indicated in the case of my son/daughter/ward during his/her period of training, as is deemed necessary by a qualified practitioner.

I understand that care at a medical facility for non-military dependents will normally be rendered on a temporary (emergency) basis only; if further care is indicated, the patient will be transferred to non-military care as soon as possible. Emergency care provided to cadets who are not military dependents at a military medical facility may be subject to reimbursement, and I may be billed for the care provided. For Navy Medical Department facilities, such care is authorized by NAVMEDCOMINST 6320.3B.

Under the authority of 5 U.S.C. Sec. 301, the information regarding your child’s/ward’s health, medical condition, and treatment is requested in order to verify any need to administer medication and to enable medical/dental personnel to diagnose and treat any emergency condition which may arise during training. Pursuant to the Privacy Act, 5 U.S.C. Sec 552, the requested information will not be divulged without your written authorization to anyone other than MCJROTC personnel involved with administration of MCJROTC activities and medical/dental personnel requiring the information in order to effectively treat any medical/dental problem which may arise. Disclosure is voluntary; however, failure to provide the requested information will preclude your child’s/ward’s participation in the program.