2023 Alaska Wing Conference CIVIL AIR PATROL CADET ACTIVITY PERMISSION SLIP

2023 Alaska Wing Conference CIVIL AIR PATROL CADET ACTIVITY PERMISSION SLIP
Email address of person completing this form
example@example.com
Cadet Name
Cadet Grade/Rank
CAPID (6 digits starting with 6 or 7)
Unit Charter Number (e.g. PCR-AK-093)
2. INFORMATION about the ACTIVITY
Name of SM Supervising your squadron's cadets
Supervising Senior initial to acknowledge responsibility:

3. PARENT’s or GUARDIAN’s CONTACT INFORMATION
Parent or Guardian Name
Relationship to Cadet
Contact phone number on date(s) of activity
Please enter a valid phone number.Format: (000) 000-0000.
5. PARENT’s or GUARDIAN’s AUTHORIZATION Cadets who have reached the age of majority, write “N.A.”

I authorize my cadet to participate in the activity described above.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
EMERGENCY INFORMATION
Insurance/Physician Information, Emergency Contacts, Minor Consents
Cadet's Home Address

Mailing Address (Number and Street)

Street Address Line 2

CityState

Zip Code
(Area Code) Home Phone
Format: (000) 000-0000.
(Area Code) Cell Phone
Format: (000) 000-0000.
Medical Insurance Company
Medical Insurance Company
Policy Number
Group Code/Number
Co-Pay Amount
Prescription Coverage Company
Policy Number
Group Code/Number
Co-Pay Amount
Family Physician
Name
Physician's Address

Mailing Address (Number and Street)

Street Address Line 2

CityState

Zip Code
Emergency Contact (Parent, guardian or closest relative to be notified in case of emergency)
Emergency Contact's Address

Mailing Address (Number and Street)

Street Address Line 2

CityState

Zip Code
Unit Commander Name and Grade
Unit Name
(Area Code) Unit Commander Day Phone
Format: (000) 000-0000.
(Area Code) Unit Commander Night Phone
Format: (000) 000-0000.
Should be Empty:

2023 Alaska Wing Conference CIVIL AIR PATROL CADET ACTIVITY PERMISSION SLIP

EMERGENCY INFORMATION

Insurance/Physician Information, Emergency Contacts, Minor Consents

Medical Insurance Company

Family Physician