Emergency Information
Insurance/Physician Information, Emergency Contacts, Minor Consents
Name (Last, First, Middle)
*
CAP Grade
*
Please Select
C/Amn
C/A1C
C/SrA
C/SSgt
C/TSgt
C/MSgt
C/SMSgt
C/CMSgt
C/2d Lt
C/1st Lt
C/Capt
C/Maj
C/Lt Col
C/Col
SM
SSgt
TSgt
MSgt
SMSgt
CMSgt
2d Lt
1st Lt
Capt
Maj
Lt Col
Col
Brig Gen
Maj Gen
CAPID
*
Charter Number
*
Address
*
Mailing Address (Number and Street)
Street Address Line 2
City
State
Zip Code
Home Phone
Cell Phone
*
Primary Insurance Information (upload or fill out)
Upload a copy of medical insurance cards, front and back
*
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Medical Insurance Company
*
Policy Number
Group Code/Number
Co-Pay Amount
Prescription Coverage Company
Policy Number
Group Code/Number
Co-Pay Amount
Family Physician
Physician Name
*
Physician Phone Number
*
Physician Address
*
Mailing Address (Number and Street)
Street Address Line 2
City
State
Zip Code
Emergency Contact
Parent, Guardian, or closest relative to be notified in case of emergency
Emergency Contact Name
*
Last, First Middle Initial
Relationship to Applicant
*
Address
*
Mailing Address (Number and Street)
Street Address Line 2
City
State
Zip Code
Emergency Contact Cell Number
*
Emergency Contact Home Number
Emergency Contact Work Phone Number
Emergency Contact Pager Number
Unit Commander Name and Grade
*
Unit Name
*
Unit Commander Cell Phone Number
*
Unit Commander Home Phone Number
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