Cadet Permission, Health Information And Privacy Act Statement Form printable pdf download

Appendix 6 to Annex C to the RCS JROTC SOP [25 April 08]

Rutherford County JROTC

Privacy Act Statement Form

Cadet Permission, Health Information and

The following information is necessary for enrollment in the Rutherford County Junior Reserve Officer

Training Corps (JROTC) at ____________________High School. It will be used only for the purposes

of completing a cadet record folder of military achievements and for compiling statistics for program use.

Failure to provide this information could result in disenrollment from the course. See Title 10, USC

2031, for specific information on the 1974 Privacy Act.

[Not annually required; but each enrolled

student must have this form on file in his/her unit’s cadet folder]

Cadet Name __________________________________________________________

(Last)

(First)

(MI)

Address _____________________________________________________________

(Street Address)

(Apt #)

_____________________________________________________________

(City)

(State)

(Zip)

Telephone # __________________________

Date of Birth ______/_____/_______

Place of Birth ________________________

____________

(City or County)

(State)

US Citizen: Yes ____ No ____ (If naturalized, country of origin: _________________)

Parent/Guardian: Name _________________________________________________

Address _______________________________________________

Telephone _____________________________________________

Emergency Work Number ________________________________

Family Doctor: Name _________________________________________________

Address _______________________________________________

Telephone _____________________________________________

My/our son/daughter/ward has no medical condition or impairment, which would preclude his/her full

•

participation in JROTC, and has my/our permission to participate in any and all JROTC sponsored

classes, training, or activities. Any allergies, medical conditions, etc., which limit participation are

noted in the space below. (If none, state “NONE”)

In case of an accident or illness, if the school is unable to contact me, I hereby authorize the school to

•

take my child to the abovementioned doctor. If it is impossible to contact this doctor, the school may

take my child to a doctor or hospital authorized by school officials.

I have read or had explained to me the applicable portions of the Privacy Act of 1974. I also

•

understand my responsibilities when in possession of the government property issued by the JROTC

instructors and agree to accept responsibility for the items.

____________________

___________________________

(Date)

(Signature of parent/guardian

)

C-6-1

Cadet Permission, Health Information And Privacy Act Statement Form

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