ÐÏà¡±á>þÿ 8>þÿÿÿÛCF;<97ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿµ[Î[Ï[Ð[Ñ[`ôöø%ú%&üúúöóúöÌü¥¬h@<$$T–l”ÐÖÖF.ÑÙ*ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ&$$T–l”‰þÖÖ.*&$$T–l”˜þÖÖ.*ÿÿÿÿ$¤<$ "JLN²´¶¸º¼¾ìîðòôöø%ú%ü%&&&ñäÖÈäº¬ž‚}sn}f`XKäDäCJOJQJjCJOJQJUmH6CJOJQJ5OJQJ5CJOJQJ j˜¹UjqÞ8; UVmH jUj$¹CJOJQJUj°¸CJOJQJUj<¸CJOJQJUjÈ·CJOJQJUjT·CJOJQJUjÜ¶CJOJQJUjf¶CJOJQJUjCJOJQJUmHjðµCJOJQJUAPPLICATION 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 FATHER’S SIGNATURE FATHER OR LEGAL GUARDIAN WITNESS FOR MOTHER’S 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 RECENTPHOTO HERE 34BCDqr|} 24HJLVXZ^`bnp„†ˆ’”ª¬ÈÊÌÎöøùõíàíÜÕÊÃµÊ¨ÊÕÊÃšÊ¨ÊÃÕ—ÕÊÃ‚Ê¨ÊÕÊÃtÊÃÕÊÃj‚CJOJQJUjCJOJQJU jUmHCJj„CJOJQJUjCJOJQJUmHjCJOJQJUCJOJQJjCJOJQJUCJOJQJ6CJ56<B*CJOJQJ6CJOJQJ5CJ5OJQJ(34CDq2\^`øÑ@Ê£¨žžž•žXD<$$T–l”€ÖÖF.ÑÙ*ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ ¤<$ ÆY¤<$&$$T–l”pþÖÖ.*„Œ¤<$&$$T–l”˜þÖÖ.*ÿÿÿÿ$¤<$ 34CDqrs{|}~ 24HJLVXZ`np„†ˆ’”ª¬®ÆÈÊÌÎöøú ,.JLNZ\^nprtz|‚ÊÌàâäîðö(*<>@PRTV\^vxŒŽšœž ´¶¸Àýûýûýùùùùùùùùùùùùùùùùùýùùùùùùùùùùùùùùýùùùùùùùùùùùùùùùùùùùùùùùýùùùùùùùýùùùùùùùùùùùùùùùùùùùùùùùùùùùù b`n–ªÎö,PZ~€‚Êòôúúúúïïúúúúú‘èúúú]$$T–l”€ÖÖˆ.' #ÑUÙ*ÿÿÿÿÿÿÿÿÿÿÿÿ„Æÿ„Æÿ„¤<$¤<$,.JLNZ\prtz|€‚ÊÌàâäîðòôö(*<>RTV\^vxŒñæÙæÒæË½æÒæË¯æÙæÒ¬ÒæËžæÙæÒ—ÒæË‰æÙæÒæË{æÙæÒæËj°CJOJQJUj,CJOJQJUCJOJQJj¨CJOJQJUCJj6CJOJQJUjhCJOJQJUCJOJQJCJOJQJjCJOJQJUmHjCJOJQJUjðCJOJQJU-ôö,<`vÄÆÈø . 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