ࡱ> Y  [bjbjWW ==`=],: ` !P+++++++$D-8/5+Y#q"##5+$U:$$$#8+#+$,$++dpÿ]#+APPLICATION FOR CAP ENCAMPMENT OR SPECIAL ACTIVITYFILL IN THE FOLLOWING PAGES AS ACCURATELY AND COMPLETELY AS POSSIBLE. PLEASE TYPE OR PRINT NEATLY. IF FORMS ARE NOT LEGIBLE THEN YOU MAY NOT BE SELECTED FOR THE ENCAMPMENT OR SPECIAL ACTIVITY THAT YOU WANT TO ATTEND HANDRITTEN / TYPED USE OF THIS FORM IS PROHIBITED.NAME (Last Name, First Name, Middle Initial)  FORMTEXT      JOINED CAP: MM YY  FORMTEXT       CAPSN  FORMTEXT      CAP GRADE  FORMDROPDOWN UNIT CHARTER NUMBER  FORMTEXT      REGION  FORMDROPDOWN WING  FORMTEXT    MAILING ADDRESS (Number and Street)  FORMTEXT      (City)  FORMTEXT      (State)  FORMTEXT    (Zip Code)  FORMTEXT        FORMTEXT     DATE OF BIRTH: MM DD YY  FORMTEXT      HEIGHT  FORMTEXT      WEIGHT  FORMTEXT      GENDER  FORMDROPDOWN HAIR COLOR  FORMTEXT      EYE COLOR  FORMTEXT      TELEPHONE (Home):  FORMTEXT      SCHOLASTIC ACHIEVEMENT  FORMCHECKBOX  High School Graduate RELIGIOUS PREFERENCE  FORMTEXT      (Alternate):  FORMTEXT       FORMCHECKBOX  College  FORMTEXT 0 Years  FORMCHECKBOX  Post Graduate  FORMTEXT 0 YearsPRESENT OCCUPATION  FORMTEXT      (Business):  FORMTEXT      E-MAIL ADDRESS  FORMTEXT      (Fax):  FORMTEXT      DO YOU WISH TO ATTEND MORE THAN ONE SPECIAL ACTIVITY OR ENCAMPMENT?  FORMCHECKBOX  YES  FORMCHECKBOX  NOSPECIAL ACTIVITY OR ENCAMPMENT LOCATION SLOT DESIRED (If other than Basic/General Participant) RANK ORDER  FORMCHECKBOX  AIR EDUCATION AND TRAINING COMMAND FAMILIARIZATION COURSE  FORMTEXT     FORMTEXT    FORMCHECKBOX  AIR FORCE SPACE COMMAND FAMILIARIZATION COURSE  FORMTEXT     FORMCHECKBOX  Escort (FL Only)  FORMTEXT    FORMCHECKBOX  CADET OFFICER SCHOOL  FORMCHECKBOX  Cadet Staff  FORMCHECKBOX  Seminar Advisor  FORMTEXT    FORMCHECKBOX  HAWK MOUNTAIN RANGER SCHOOL  FORMCHECKBOX   FORMTEXT        FORMTEXT    FORMCHECKBOX  NATIONAL BLUE BERET  FORMCHECKBOX  Cadet Staff  FORMCHECKBOX  Senior Staff  FORMTEXT    FORMCHECKBOX  NATIONAL FLIGHT ENCAMPMENT  FORMTEXT     FORMCHECKBOX  Administrative  FORMCHECKBOX  Instructor  FORMCHECKBOX  Maintenance  FORMTEXT    FORMCHECKBOX  NATIONAL GLIDER ENCAMPMENT  FORMTEXT     FORMCHECKBOX  Administrative  FORMCHECKBOX  Instructor  FORMCHECKBOX  Maintenance  FORMTEXT    FORMCHECKBOX  NATIONAL GROUND SEARCH AND RESCUE SCHOOL  FORMCHECKBOX  Advanced  FORMCHECKBOX  Cadet Staff  FORMCHECKBOX  Senior Staff  FORMTEXT    FORMCHECKBOX  PARARESCUE ORIENTATION COURSE  FORMTEXT     FORMTEXT    FORMCHECKBOX  ADVANCED PARARESCUE ORIENTATION COURSE  FORMCHECKBOX  Mountaineering  FORMCHECKBOX  Navigation  FORMTEXT   OTHER SPECIAL ACTIVITY OR ENCAMPMENT (National, Region, or Wing)  FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT   CAP FORM 31 NOV 96 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE. CONTINUE ON TO BACK TO BE COMPLETED BY FLIGHT AND GROUND INSTRUCTOR APPLICANTSFAA CERTIFICATES AND RATINGS  FORMTEXT      CFI CERTIFICATE NUMBER & EXPIRATION DATE  FORMTEXT        FORMTEXT      MEDICAL CERTIFICATE CLASS & DATE  FORMTEXT        FORMTEXT      TOTAL FLIGHT TIME IN HOURS  FORMTEXT      TOTAL FLIGHT TIME IN HOURS (Last 12 Months)  FORMTEXT      AIRCRAFT FLOWN (Last 12 Months)  FORMTEXT      TOTAL FLIGHT INSTRUCTION GIVEN IN HOURS  FORMTEXT      FLIGHT INSTRUCTION GIVEN IN HOURS (Last 12 Months)  FORMTEXT      AIRCRAFT FLOWN IN INSTRUCTION (Last 12 Months)  FORMTEXT      TOTAL SOLO ENDORSEMENTS  FORMTEXT      TOTAL SOLO ENDORSEMENTS (Last 12 Months)  FORMTEXT      AIRCRAFT FLOWN IN SOLOS ENDORSED (Last 12 Months)  FORMTEXT      CAP FORM 5 CHECKRIDE DATE  FORMTEXT      AIRCRAFT MAKES AND MODEL AUTHORIZED ON CAPF5  FORMTEXT       PLEASE INCLUDE A COPY OF YOUR PILOT LOGBOOK FOR THE LAST 12 MONTHS AND A COPY OF YOUR CURRENT CAPF 5 WITH THIS APPLICATION.TO BE COMPLETED BY MAINTENANCE OFFICER APPLICANTSFAA CERTIFICATES AND RATINGS  FORMTEXT      CERTIFICATE NUMBER & EXPIRATION DATE  FORMTEXT        FORMTEXT      TO BE COMPLETED BY INTERNATIONAL AIR CADET EXCHANGE APPLICANTSFOREIGN LANGUAGE EXPERIENCE LANGUAGESPEAKING ABILITYWRITING ABILITYOVERALL UNDERSTANDING FORMTEXT       FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMTEXT       FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  PoorCOUNTRY PREFERENCE (Countries are announced each year in the November issue of the Civil Air Patrol News.)1.  FORMTEXT      2.  FORMTEXT      3.  FORMTEXT      AIRPORT INFORMATION (List the Name, City, and State of the two closest major airports within 250 miles of your home. This information will be used to purchase your airline ticket once selected.)1.  FORMTEXT        FORMTEXT      2.  FORMTEXT        FORMTEXT      RELEVANT EXPERIENCE (Use this section to relate any CAP or non-CAP experiences that could have a beneficial impact on your being selected to attend the special activity or encampment that you have requested. Use an additional sheet if necessary, but please limit additional documentation.)  FORMTEXT      CAP FORM 31 NOV 96 PAGE 2/4 CONTINUE ON TO NEXT PAGE MEDICAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS This information is for Official Use Only and will not be released to unauthorized persons. Answer all questions as accurately as possible so that special activity or encampment staff can make themselves aware of any pre-existing medical problems or conditions and be alert to help you.HAVE YOU EVER HAD AN FAA OR OTHER FLIGHT PHYSICAL DENIED, SUSPENDED, OR REVOKED?  FORMCHECKBOX  NO  FORMCHECKBOX  YES (Give the date and reason in the remarks section.)DO YOU CURRENTLY USE ANY MEDICATION? (Including eye drops)  FORMCHECKBOX  NO  FORMCHECKBOX  YES (List any medication taken and the reason in the remarks section.)HAVE YOU HAD OR BEEN INVOLVED IN AN ACCIDENT IN THE PAST 2 YEARS?  FORMCHECKBOX  NO  FORMCHECKBOX  YES (Explain the extent of your injuries and treatment required in the remarks section.)HAVE YOU HAD OR HAVE NOW ANY OF THE FOLLOWING? (If yes is answered on any items, please explain why in the remarks section with dates and physician(s) consulted (if any). Items not specifically noted below having the potential to interfere with performance during the special activity or encampment should be documented in the remarks section.)  FORMCHECKBOX  NO  FORMCHECKBOX  YES Frequent or severe headaches  FORMCHECKBOX  NO  FORMCHECKBOX  YES Ear infections  FORMCHECKBOX  NO  FORMCHECKBOX  YES Chronic diseases like Diabetes or Bronchitis  FORMCHECKBOX  NO  FORMCHECKBOX  YES Dizziness or fainting spells  FORMCHECKBOX  NO  FORMCHECKBOX  YES Rupture  FORMCHECKBOX  NO  FORMCHECKBOX  YES Girls only - Menstrual cramps  FORMCHECKBOX  NO  FORMCHECKBOX  YES Unconsciousness for any reason  FORMCHECKBOX  NO  FORMCHECKBOX  YES Positive TB skin test  FORMCHECKBOX  NO  FORMCHECKBOX  YES Other illness or accidents  FORMCHECKBOX  NO  FORMCHECKBOX  YES Eye trouble, excluding glasses  FORMCHECKBOX  NO  FORMCHECKBOX  YES Epilepsy or fits  FORMCHECKBOX  NO  FORMCHECKBOX  YES Military rejection or medical discharge  FORMCHECKBOX  NO  FORMCHECKBOX  YES Hay fever  FORMCHECKBOX  NO  FORMCHECKBOX  YES Kidney stones or blood in urine  FORMCHECKBOX  NO  FORMCHECKBOX  YES Rejection for life insurance  FORMCHECKBOX  NO  FORMCHECKBOX  YES Sugar or albumin in urine  FORMCHECKBOX  NO  FORMCHECKBOX  YES Motion sickness  FORMCHECKBOX  NO  FORMCHECKBOX  YES Admission to hospital  FORMCHECKBOX  NO  FORMCHECKBOX  YES Heart trouble  FORMCHECKBOX  NO  FORMCHECKBOX  YES Nervous trouble of any sort  FORMCHECKBOX  NO  FORMCHECKBOX  YES Record of traffic convictions  FORMCHECKBOX  NO  FORMCHECKBOX  YES High or low blood pressure  FORMCHECKBOX  NO  FORMCHECKBOX  YES Any known allergies  FORMCHECKBOX  NO  FORMCHECKBOX  YES Record of other convictions  FORMCHECKBOX  NO  FORMCHECKBOX  YES Stomach trouble  FORMCHECKBOX  NO  FORMCHECKBOX  YES Any drug or narcotic habit  FORMCHECKBOX  NO  FORMCHECKBOX  YES Attempted suicide  FORMCHECKBOX  NO  FORMCHECKBOX  YES Asthma  FORMCHECKBOX  NO  FORMCHECKBOX  YES Chronic or recurring injuries  FORMCHECKBOX  NO  FORMCHECKBOX  YES Medical treatment within the past 5 years other than regular office visits or physicalsIMMUNIZATIONS  FORMTEXT      FAMILIY PHYSICIAN (Name, address, and phone number)  FORMTEXT        FORMTEXT        FORMTEXT      INSURANCE INFORMATION  FORMCHECKBOX  Medical  FORMCHECKBOX  Liability Company Company  FORMTEXT        FORMTEXT       Policy Number Policy Number  FORMTEXT        FORMTEXT      EMERGENCY ADDRESSEE - PARENT, GUARDIAN, OR CLOSEST RELATIVE TO BE NOTIFIED IN CASE OF EMERGENCY Name Relationship  FORMTEXT        FORMTEXT       Address Press shift-Enter to add a line to this entry Day Telephone Night Telephone  FORMTEXT        FORMTEXT        FORMTEXT      REMARKS  FORMTEXT      CAP FORM 31 NOV 96 PAGE 3/4 CONTINUE ON TO LAST PAGE RELEASE AGREEMENTKNOW ALL MEN BY THESE PRESENTS that I am submitting my application for Civil Air Patrol Special Activities or Encampments, and I hereby volunteer entirely upon my own initiative, risk, and responsibility for an assignment to participate in this activity of encampment at the first available opportunity and with full knowledge that such activity may include: 1. Traveling by land, sea, or air in US military, commercial, or privately owned vehicles from regular place or residence to the site of the activity or encampment, travel incident to the activity or encampment, and subsequent return to place of residence. 2. Participation in aeronautical activities as a passenger or student trainee in US military, commercial, or privately owned aircraft. 3. Living for a period of one week or more on diminished rations and minimal shelter simulating actual survival conditions. 4. Being quartered and/or subsisting away from regular or normal place of residence for an extended period of time. 5. Remaining with the cadet group I am assigned to at all times during the activity or encampment. 6. Acting as a spokesman for Civil Air Patrol, rendering reports on the activity or encampment. 7. Refraining from argumentative discussions concerning governmental policies. In consideration of the permission extended to me by the Civil Air Patrol/United States of America through its officers and agents to participate in said activity/encampment or activities/encampments, I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Civil Air Patrol, Inc./United States of America, and all its officers, agents, and employees acting official or otherwise, from any and all claims, demands, actions, or causes of action, on account of my death or on account of any injury to me or my property which may occur as a result of the negligence of the Civil Air Patrol/United States of America, its agents or employees during said activity/encampment or activities/encampments or continuances thereof, as well as all ground and flight operations incident thereto. DATE SIGNATURE OF APPLICANTRELEASE BY PARENTS OR GUARDIAN KNOW ALL MEN BY THESE PRESENTS: WHEREBY my child has applied for the activity or encampment referred to above, In consideration of the permission extended to my child by the Civil Air Patrol/United States of America through its officers and agents to participate in said activity/encampment or activities/encampments, I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Civil Air Patrol, Inc./United States of America, and all its officers, agents and employees acting official or otherwise, from any and all claims, demands, actions or causes of action, on account of the death or on account of any injury to my child which may occur as a result of the negligence of the Civil Air Patrol/United States of America, its agents or employees during said activity/encampment or activities/encampments or continuances thereof, as well as all ground and flight operations incident thereto. In addition, by my signature below, I certify the applicant: 1. Is my minor child or ward. 2. Has no history or injury or disease which might be affected by this activity except those previously noted in the Medical Information section of this form. 3. Will follow all rules, regulations, and directives as established by the Civil Air Patrol, Inc., activity project officer or encampment commander, or other staff members. If not following the above mentioned rules, regulations, and directives he/she may be sent home at the discretion of the project officer, encampment commander or activity directory at my expense. However, in case of injury, disease or other illness, permission is hereby granted to treat the applicant as required, and if the applicant is released from the activity before recovery from said injury, disease, or illness, further treatment will be provided by myself. DATE WITNESS FOR FATHERS SIGNATURE FATHER OR LEGAL GUARDIAN WITNESS FOR MOTHERS SIGNATURE MOTHER OR LEGAL GUARDIANSQUADRON CERTIFICATION I certify that the above information is correct and that all requirements for attendance, as specified in National Headquarters Directives, will be completed by the required dates. This applicant is the choice of cadets/seniors in this squadron applying for . SQUADRON COMMANDERWING CERTIFICATION (Mandatory for all but Region Staff Applicants) This applicant is the choice of cadets/seniors in this Wing applying for . WING COMMANDER / BOARD PRESIDENTREGION CERTIFICATION (IACE Escorts and Region Staff Applicants Only) This applicant is the choice of cadets/seniors in this Region applying for . REGION COMMANDERAPPLICATION CHECKLIST  FORMCHECKBOX  APPLICATION IS FILLED OUT COMPLETELY AND LEGIBLY, AND HAS ALL SUPPORTING DOCUMENTATION ATTACHED  FORMCHECKBOX  APPROPRIATE NUMBER OF COPIES OF APPLICATION HAVE BEEN MADE (3 FOR NATIONAL CADET SPECIAL ACTIVITES)  FORMCHECKBOX  REQUIRED SIGNATURES HAVE BEEN OBTAINED  FORMCHECKBOX  CHECK(S) OR MONEY ORDER(S) IS(ARE) ATTACHED IF REQUIRED (CHECKS ARE MAILED SEPARATELY FOR NATIONAL CADET SPECIAL ACTIVITIES)  FORMCHECKBOX  COPIES HAVE BEEN FORWARDED OR RETAINED AS REQUIRED (FOR NATIONAL CADET SPECIAL ACTIVITIES MEMBERS RETAIN ONE COPY, FORWARD ONE TO THEIR WING REVIEW BOARD, AND FORWARD THE THIRD COPY TO NATIONAL HEADQUARTERS BY 31 JANUARY AT THE FOLLOWING ADDRESS: HQ CAP/CP 105 SOUTH HANSELL STREET MAXWELL AFB AL 36112-6332CAP FORM 31 NOV 96 PAGE 4/4 ATTACH RECENT PHOTO HERE 34 BCDqr|}  24HJLVXZ^`bnp õʨÚʨ՗ÂʨtjCJOJQJUjCJOJQJU jUmHCJ jCJOJQJUjCJOJQJUmHjCJOJQJU CJOJQJjCJOJQJU CJ OJQJ6CJ 56<B*CJOJQJ6CJ OJQJ5CJ 5OJQJ(34CDq2\^`@XD<$$Tl    F. *  <$ Y<$&$$Tlp    . * <$&$$Tl    . *$<$ 34CDqrs{|}~  24HJLVXZ`np  ,.JLNZ\^nprtz|(*<>@PRTV\^vx b`n,PZ~]$$Tl    ֈ.' #U *  <$<$ ,.JLNZ\prtz|(*<>RTV\^vx˽˯Ҭ˞җˉ{jCJOJQJUj,CJOJQJU CJOJQJjCJOJQJUCJ j6CJOJQJUjhCJOJQJU CJOJQJ CJ OJQJjCJOJQJUmHjCJOJQJUjCJOJQJU-,<`v . ͤw|G$$Tl    \.} *   <$ ;<$1$$Tl    0. *       . 0 D F H R T d f z | ~ 潶ҨҚҌ~pj CJOJQJUj& CJOJQJUjCJOJQJUjCJOJQJUjCJOJQJU CJOJQJ CJ OJQJjCJOJQJU CJOJQJjCJOJQJUmHjCJOJQJUj$CJOJQJU,     . 0 2 B D F H R T d f h x z | ~    & ( * 4 6 \ ^ r t v   . 0 D F H R T p r    V X  c. 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