Cnet Form 1533/106 Njrotc Standard Release Form printable pdf download

NAVAL JUNIOR RESERVE OFFICERS TRAINING CORPS

(NJROTC)

STANDARD RELEASE FORM

Date: ___________________

I, ___________________________________________________________, being the legal

parent/guardian of __________________________________________________, a member of

the Naval Junior Reserve Officers Training Corps, in consideration of the continuance of his/her

membership in the Naval Junior Reserve Officers Training Corps and/or his/her acceptance for

Naval Junior Reserve Officers Training Corps training, 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 Navy 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 military 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 facility may be subjected to reimbursement, and I may be

billed for the care provided. For Navy Medical Department facilities, such care is authorized by

NAVMEDCOMINST 6320.3B.

My son/daughter/ward has been determined to have the following allergies:

He/she requires medication for the treatment of:

Below are listed other medical conditions which my son/daughter/ward is known to have, which would

preclude or limit in any way his/her participation in physical exercise and athletic programs.

His/her physician is:

Name:

Address:

Telephone (include area code):

Initials ______

CNET – GEN 5800/4 (Rev. 1-00)

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Cnet Form 1533/106 Njrotc Standard Release Form