Af Form 1181 - Air Force Youth Flight Program Patron Registration
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1AIR FORCE YOUTH FLIGHT PROGRAM PATRON REGISTRATION
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 8013; 44 USC 3101; EO 9397
PRINCIPAL PURPOSES: To provide Youth Flight Programs with authorization for medical treatment in emergency situations; authorization for field trips;
identify children and sponsor, record required immunizations; record known allergies; record income data; record special needs requirements; and record
special instructions.
ROUTINE USES: Form may be furnished to civilian doctors or hospitals in course of obtaining emergency medical attention for children. Information
furnished may be disclosed, upon request, to other Federal, state or local governmental agencies in the pursuit of their official duties. Finally, it may be
used for other lawful purposes including law enforcement and litigation.
DISCLOSURE IS VOLUNTARY: Failure to furnish information, including SSN, will result in denial of admission of child(ren) to Youth Flight Programs.
SSN is used for positive identification of individuals and records.
CHILD’S NAME
FEES
(Last, First, Middle Initial)
(Last, First, Middle Initial)
SPONSOR
SPOUSE
DEROS/ID EXPIRES
HOME PHONE
RANK/GRADE
RANK/GRADE
BRANCH OF SERVICES
ADDRESS
DUTY PHONE
DUTY PHONE
EMERGENCY PHONE
ORGANIZATION
EMERGENCY CONTACT
HOSPITAL PHONE
MARITAL STATUS
SPONSOR’S SSN
SPOUSE’S SSN
PHYSICIAN’S NAME
MALE
DATE OF BIRTH
SEX
BIRTH
2
4
6
12
15
18
4-6
11-12
14-16
VACCINE /
(Day, Month, Year)
(X One)
MOS
MOS
MOS
MOS
MOS
MOS
MOS
MOS
MOS
DATE RECEIVED
FEMALE
Hepatitis B
I authorize emergency treatment for the children
1st
named hereon:
Hep B-1
2nd
3rd
Hep B-2
Hep B-2
Hep B
4th
Diphtheria-Tetanus,
Pertussis
SIGNATURE
DATE (YYYYMMDD)
1st
2nd
3rd
SPECIAL INSTRUCTIONS
Td
DTP
DTP
DTP
DTP
DTP
OR
4th
DTAP
5th
6th
H.Influenzane type b
1st
2nd
3rd
Hib
Hib
Hib
Hib
4th
Polio
SPECIAL NEEDS CARE /CHRONIC ILLNESSES /ALLERGIES
1st
2nd
3rd
OPV
OPV
OPV
OPV
4th
Measles, Mumps,
Rubella
MMR OR MMR
1st
MMR
2nd
ADULTS AUTHORIZED TO SIGN CHILDREN IN / OUT
Varicella Zoster
Virus Vaccine
1st
VZV
VZV
2nd
OTHER IMMUNIZATIONS AS REQUIRED:
NAMES OF ADDITIONAL CHILDREN
AUTHORIZED FOR FIELD TRIPS
ENROLLED IN PROGRAM:
VACCINE TYPE:
DATE:
VACCINE TYPE:
DATE:
VACCINE TYPE:
DATE:
VACCINE TYPE:
DATE:
FAMILY INCOME (Adjusted gross—most recent 1040) : PROVIDE ONLY IF REDUCED FEES ARE REQUESTED.
IT IS THE RESPONSIBILITY OF EACH SPONSOR TO
ENSURE IMMUNIZATIONS AND EMERGENCY
$
$
SINGLE / DUAL INCOME
(Circle One)
INFORMATION IS UP TO DATE. FAILURE TO UPDATE
PARENT SIGNATURE
MAY RESULT IN REFUSAL OF SERVICE.
AF FORM 1181, 19960501 (EF-V3)
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