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
SPONSOR (Last, First, Middle Initial)
SPOUSE (Last, First, Middle Initial)
FEES
DEROS/ID EXPIRES
HOME PHONE
RANK/GRADE
RANK/GRADE
BRANCH OF SERVICE
ADDRESS
DUTY PHONE
DUTY PHONE
EMERGENCY PHONE
ORGANIZATION
EMERGENCY CONTACT
HOSPITAL PHONE
SPONSOR'S SSN
SPOUSE'S SSN
MARITAL STATUS
PHYSICIAN'S NAME
SEX
MALE
DATE OF BIRTH (Day, Month, Year)
VACCINE /
2
4
6
12
15
18
4-6
11-12
14-16
BIRTH
(X One)
MOS
MOS
MOS
MOS
MOS
MOS
YRS
YRS
YRS
DATE RECEIVED
FEMALE
I authorize emergency treatment for the children named
Hepatitis B
hereon:
1st
Hep B-1
2nd
3rd
Hep B-2
Hep B-3
Hep B
4th
Diphtheria-Tetanus,
SIGNATURE
DATE
Pertussis
(YYYYMMDD)
1st
2nd
3rd
DTP
Td
DTP
DTP
DTIP
DTP
SPECIAL INSTRUCTIONS
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
1st
MMR
MMR OR MMR
2nd
Varicella Zoster
Virus Vaccine
1st
VZV
VZV
2nd
NAMES OF ADDITIONAL CHILDREN
OTHER IMMUNIZATIONS AS REQUIRED:
ADULTS AUTHORIZED TO SIGN CHILDREN IN / OUT
ENROLLED IN PROGRAM:
VACCINE TYPE:
DATE:
VACCINE TYPE:
DATE:
VACCINE TYPE:
DATE:
VACCINE TYPE:
DATE:
AUTHORIZATION FOR FIELD TRIPS
FAMILY INCOME
:
(Adjusted gross--most recent 1040)
PROVIDE ONLY IF REDUCED FEES ARE REQUESTED.
$
SINGLE / DUAL INCOME
$
(Circle One)
IT IS THE RESPONSIBILITY OF EACH SPONSOR
TO ENSURE IMMUNIZATIONS AND EMERGENCY
PARENT SIGNATURE
INFORMATION IS UP TO DATE. FAILURE TO
UPDATE MAY RESULT IN REFUSAL OF SERVICE.
AF FORM 1181, 19960501 (EF-V3)
PREVIOUS EDITION IS OBSOLETE.
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