Cnet Form 1533/106 Njrotc Standard Release Form (Page 2 of 3) in pdf

Cnet Form 1533/106 Njrotc Standard Release Form Page 2

Medical Insurance Company *

Name:

Street:

City, State, Zip Code:

Policy/ID Number:

Telephone Confirmation Number: (

)

Dental Insurance Company*

Name:

Street:

City, State, Zip Code:

Policy/ID Number:

Telephone Confirmation Number: (

)

*This insurance is not required. However, the information provided may be required to

obtain non-emergency care.

PRIVACY ACT NOTIFICATION

Under the authority of 5 U.S.C. Sec. 301, the information regarding your child’s/ward’s health,

medical condition and treatment is requested in order to verify any need to administer medication

and to enable medical/dental personnel to diagnose and treat any emergency condition which

may arise during training. Pursuant to the Privacy Act, 5 U.S.C. Sec. 552, the requested

information will not be divulged without your written authorization to anyone other than

NJROTC area personnel involved with administration of NJROTC activities and medical/dental

personnel requiring the information in order to effectively treat any medical/dental problem

which may arise. Disclosure is voluntary: however, failure to provide the requested information

will preclude your child’s/ward’s participation in the training.

Signature of Parent or Guardian:

Address:

City:

State:

Zip:

Telephone (include area code):

CNET – GEN 5800/4 (Rev. 1-00)

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Cnet Form 1533/106 Njrotc Standard Release Form Page 2