Nsctng 004 - Navy Report Form - Locally Arranged Training Authority (Officer) Page 2

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Non-Transferable

TRAINING AUTHORITY

Officer Orders (local)

4. Have you completed Officer Professional Development Courses?

Yes

If Yes, which ones?

101

201

301

5. STATEMENT OF UNDERSTANDING (MEDICAL & STANDARDS OF CONDUCT)

Member

Initial Below

BY INITIALING YOU CERTIFY YOUR UNDERSTANDING & CONSENT TO THE FOLLOWING PARAGRAPHS:

5a. I have been advised and understand that the training/escort duty requested is strenuous and both physically and mentally demanding.

Since my last full physical, I have not been advised to have any surgery or major medical procedures performed. Further, I certify that I have

NO outstanding or ongoing medical conditions that will preclude my carrying out my duties as assigned by (and discussed with) the COTC for

this training. I understand that should a disqualifying medical or physical condition arise prior to my departure for training I must notify my unit

commanding officer immediately, and I understand authority to participate in the training requested will be cancelled.

5b. I authorize any Health Care Provider, Insurance Company, Employer, Person, or Organization to release any information regarding

medical, dental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information concerning

the patient to the Naval Sea Cadet Corps’ Accident Insurance Provider, the Plan Administrator, or their employees and authorized agents for

the purpose of validating and determining benefits payable. This data may be extracted for audit purposes or for statistical analysis. I

understand that my authorized representative or I will receive a copy of this authorization upon request.

5c. Officers/Midshipmen/Instructors are responsible for maintaining the highest standards of conduct. I affirm that I will abide by all NSCC

Regulations and instructions from the COTC and host command. I understand that the consumption of alcoholic beverages in the presence

of cadets or in cadet living spaces is prohibited at all times. Further, should I consume alcohol, I understand that I am not to have any contact

with cadets for a minimum of eight hours from the time of consumption. I also understand that use of tobacco products is to be done in an

authorized area and not in view of cadets. I certify that I have read and understand the NSCC sexual harassment and hazing policies. I

understand that violation of NSCC Regulations is cause for immediate dismissal from the training contingent.

6a. Medical Insurance Provider Name

6b. Medical Insurance Policy Number

6c. Medical Insurance Provider Address

6d. Medical Insurance Provider Phone

7. TRANSPORTATION NOTICE

The Department of the Navy no longer has the scheduling authority to support the Naval Sea Cadet Corps for air transportation needs. The NSCC Unit, Unit Sponsor, Council,

or individual MUST provide for transportation to and from the training site. Transportation of NSCC personnel returned home for disciplinary reasons, illness, or at own

request, will be at their OWN EXPENSE or at the expense of their NSCC UNIT OR UNIT SPONSOR.

8. ENDORSEMENTS

By endorsing this form you affirm that the member is physically and mentally qualified to attend the requested training and that all information provided, to

the best of your knowledge, is truthful and accurate; and you consent to the above listed NSCC/NLCC training and all terms and conditions of the preceding

paragraphs.

8a. Member (Print or Type)

8b. Signature

8c. Date (DD MMM YY)

8d. Commanding Officer (Print or Type)

8e. Signature

8f. Date (DD MMM YY)

8g. Commanding Officer’s Primary Phone Number

8h. Commanding Officer’s Alternate Phone Number

8i. Commanding Officer E-Mail Address

THE ABOVE MUST BE COMPLETED AND SIGNED PRIOR TO DEPARTURE FOR TRAINING

9. SPECIAL NOTES