CENTRAL HARDIN JROTC STUDENT INFORMATION AND MEDICAL RELEASE
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 students participating in the JROTC program and activities.
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.
4. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Disclosure is voluntary. Refusal to provide information or sign release will result in no detriment to the student. Refusal to provide information and sign will require further inquiry for personal data pertinent to the students, release of which may be mandatory for enrollment to continue in the JROTC program.
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STATEMENT: Signature of Student and Parent/Guardian Required on Page 2
1. I have read the applicable portion of the Privacy Act of 1974, located on this form. I hereby give my permission for my student to participate in any or all JROTC activities and to travel with Army Instructors, faculty and adult sponsors of the Central Hardin JROTC Department on JROTC sponsored activities. I understand that my student must have insurance to travel and participate in all off campus activities. (Minimum School Insurance can be purchased thru the school office)
2. In consideration of any loan of clothing and/or equipment by the Central Hardin High School JROTC Department to my student, I the undersigned do hereby guarantee the return of all property in the same condition as issued except for normal fair wear and tear. My student is authorized to sign an agreement receipt for such clothing and equipment issued. I agree in the event of loss or destruction of said property, or parts thereof, through the fault or neglect of my student, to reimburse the Central Hardin High School JROTC Department at the current rate of price of the property.
3. I further agree to accept responsibility for safeguarding, maintaining, and accounting for any government or school property issued to my student.
4. I hereby certify, to the best of my knowledge and belief, that my student is physically fit and capable of participation in the Central Hardin JROTC program, to include Cadet Challenge (the Presidential Fitness test) and Raider Team (if participating). I delegate the JROTC faculty or other adult sponsors the authority to execute emergency care necessary and essential for the preservation of the health and safety of my student. I further agree that I, the parent/guardian of the listed student and/or the student will notify the JROTC Department of any changes in the physical condition of the student. We recommend that your student see their doctor or have a sports physical prior to participation on the Raider Team. STATEMENT: Signature of Student and Parent/Guardian Required (continued)
Printed Student Name: ______Student Cell# ______
Date of Birth ______/______/______Grade: 9 - 10 - 11 - 12 Gender: M - F
Address ______City ______State ______Zip______
Printed Parent/Guardian Name: ______
Contact (Home/Cell) ______Work ______
Email: ______Please share with the Cadet Support contact list Y N
Family Doctor:______Phone ______
Insurance Company: ______Policy#______
Emergency Contact: ______Phone ______
2nd Emergency Contact: ______Phone ______
My student has a history of: ______
______( Such as: Asthma, Allergies, Bee Stings, Ear infection, Headaches, Heart condition)
Current Medications: ______(School nurse must also have this on file)
Allergic to the following Medications: ______
______Print Student Name Signature Date (mm/dd/yyyy) ______Print Parent/Guardian Name Signature Date (mm/dd/yyyy)