ࡱ> /1.a bjbjzz 4P\P\       044444(******$NN44c.44((4@f.PD.y0)rH))8Zi@49NN")> :  CONSENT TO MEDICAL TREATMENT STATEMENT REQUIRED BY PRIVACY ACT OF 1974 (1) AUTHORITY: TITLE 10, U.S. CODE 2102. (2) PRINCIPAL PURPOSES: A statement authorizing medical care in civilian or government medical facilities while attending or traveling to or from JCLC. (3) ROUTINE USES: Normal personnel actions: Disclosure of information may be provided to proper authorities in actions regarding medical treatment, legal actions as a result of injury or death, and investigation of accident resulting from JCLC. (4) MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary. Failure to complete form will disqualify JROTC cadet from participating in specific voluntary training exercises. I ____________________________, consent to be treated in an Army Hospital, or any other government or civilian medical facility, near or enroute to _____Camp Shelby, MS_____________________, (Installation, State) while attending or traveling to or from JCLC from _6-11 JUN 2022_____________. (MM/YY) This consent encompasses all procedures and treatments as are found to be necessary or desirable, in the judgment of the professional staff of any of the above-named medical facilities. I understand that this consent is of a general nature and accordingly list the following exceptions to this consent (if no exceptions write "No Exceptions") _______________________, _______________________________. I (am) (am not) on medication. (List type, if on medication) I (am) (am not) allergic to medication. (List type, if allergic) It is understood that this consent can be withdrawn in writing or orally at anytime. ___________________________________ ___________________________________ Signature of Witness Signature of Cadet ___________________________________ ____________________ SSN ___________ Print Name of Witness Print Name of Cadet (Last 4) PARENT OR GUARDIAN: (When cadet is a minor or unable to give consent), I ____________ _________________, parent/guardian of _________________________ have read and understood the above consent to treatment and hereby expressly consent to the above-described treatment. __________________________________ _________________________________ Signature of Witness Signature of Parent ___________________________________ ____________________ SSN ____________ Print Name of Witness Print Name of Parent (Last 4) IJKtu  ^ @ A x  01')ej۹ʫʫʇʫʫxʫʫʫʫʫʫʫʫʫʫhe9>*CJOJQJ^JaJ#he9he9>*CJOJQJ^JaJ#h}Zh}Z5CJOJQJ^JaJh}ZCJOJQJ^JaJ h}Z5CJOJQJ\^JaJ h}Zh}ZCJOJQJ^JaJ&h}Zh}Z5CJOJQJ\^JaJ h}Z5CJ(OJQJ\^JaJ(/JKu  A B  12$a$gd}Zgd}Z &d P gd}ZO`gd}Zgd}Zj~79`v{h}ZhqCJaJh}ZCJaJh}Zh}ZCJaJh}ZCJOJQJ^JaJ h}Zh}ZCJOJQJ^JaJ21h:p}Z/ =!"#$% s2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List bob }ZDefault 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] j  8@0(  B S  ?HHHHHHdd  hh&&& =*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceNameB*urn:schemas-microsoft-com:office:smarttagscountry-region9*urn:schemas-microsoft-com:office:smarttagsplace ho  BDR\ 333IJ@Ax 01')ej~  7 9 v { x e9 v:p3}Z7qUz @ @UnknownG.[x Times New Roman5Symbol3. .Cx Arial7. [ @VerdanaA$BCambria Math"1hesesn,n,!x24 3QHP ?}Z2!xx CONSENT TO MEDICAL TREATMENTLTC (R) James R. McLeodJROTC Oh+'0 $0 P \ ht| CONSENT TO MEDICAL TREATMENTLTC (R) James R. McLeodNormalJROTC2Microsoft Office Word@F#@.P@.Pn, ՜.+,0  hp   RCSD JROTC  CONSENT TO MEDICAL TREATMENT Title  !"#$%'()*+,-0Root Entry F0.P21Table)WordDocument4SummaryInformation(DocumentSummaryInformation8&CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q