ࡱ> 463a bjbjzz 4$P\P\     ,8 0TTTTT///$F//TT999 TT9999Tw!.P:90999H/L{69,///////////////> :  CADET INFORMATION STATEMENT REQUIRED BY PRIVACY ACT OF 1974 1. AUTHORITY: Title 10, U.S. Code 2102 2. PRINCIPAL PURPOSE(S): To gather information, emergency points of contact, and statement of the physical condition of JROTC cadets attending JCLC. 3. ROUTINE USES: Normal Personnel Actions--Disclosures of information may be provided to proper authorities in actions regarding medical treatment, legal actions, investigation of accidents, and preparation of statistics and training records resulting from JCLC. 4. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDIDNG INFORMATION: Disclosure is voluntary. Failure of cadet to complete form will disqualify JROTC cadet from participating in JCLC. 1. Cadet: __________________________________________________________M / F___ (Rank, Last Name, First, MI) (Gender) 2. ________________ __________________________________________ (Last 4 of SSN) (Name of School) 3. Parent or Guardian _________________________________________________________ (Name and Address) 4. Telephone: _____________________ Other: _________________________ 5. Family Doctor: _____________________________________________________________________ (Name and Address) 6. Telephone: ______________________ Other: ___________________________ 7. Dentist: ________________________________________________________________________ (Name and Address) 8. Telephone: ______________________ Other: _________________________ NOTE: IF PARENT OR GUARDIAN CANNOT BE CONTACTED, PLEASE LIST ONE OTHER PERSON TO CONTACT IN CASE OF AN EMERGENCY. 10. Emergency Contact: _______________________________________________________________ (Name and Address) 11. Telephone: _____________________ Other: _________________________ STATE OF PHYSICAL CONDITION (_____) Initials To the best of my knowledge, my son/daughter/ward is in good physical condition. Participation in JCLC, in my opinion, will not have an adverse effect on his/her health and well-being. I will inform the JCLC Commander of any changes. (_____) Initials My son/daughter/ward has a history of (identify illnesses; Heart disease, Asthma, Overweight, Sinus, Rheumatic Fever, Ear Infection, Headaches, or any other ailments) ___________________________________, and is on ___________________________________________medication. He/she is allergic to the following medication: _____________________________________________. NOTE: Students that are found to have previous history of any type illness, past injury, and/or symptoms of suspected medical aliment, will be returned home if treatment is needed or desired. DENTAL RECORDS I acknowledge my dental records contain detail profiles and/or x-rays of sufficient detail for identification. 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