U.S. NAVAL SEA CADET CORPS U.S. NAVY LEAGUE CADET CORPS CADET APPLICATION INSTRUCTIONS: PLEASE PRINT OR TYPE ONLY FILL IN ALL BLOCKS THAT APPLY, THOSE THAT DO NOT, ENTER "NOT APPLICABLE" OR N/A 1. APPLICANT INFORMATION 1a. Last Name 1b. First Name 1c. Middle Name 1e. Home Address 1g. State 1h. Zip Code + 4 1i. Social Security Number 1j. Date of Birth (DD MMM YY) 1k. Home Phone 1l. E-Mail Address 1m. Full-time Student? 1n. School Name & City 1p. Has the applicant ever been charged OR convicted of a criminal offense? (use an additional sheet if necessary) 1r. Citizenship 1s. Referred/Recruited by
U.S. Citizen (NSCC Regulations, Chapter Six, Paragraph 0610.1, U.S. Citizenship Required)
2. APPLICANT AGREEMENT AND CONFIRMATION
I agree to be governed by the regulations for administration of the NSCC/NLCC; and to obey all lawful orders, to attend drills regularly, and to take proper care of any uniforms or equipment entrusted to me. I also commit to being drug, alcohol, and gang free while I am a member of the NSCC/NLCC. 2a. Applicant Signature 2b. Date (DD MMM YY) 3. PRIMARY PARENT/LEGAL GUARDIAN INFORMATION (will be listed as next of kin and first contact in case of an emergency) 3b. Relationship 3c. Address 3e. State 3f. Zip Code + 4 3g. Day Phone 3h. Evening Phone 3i. E-Mail Address 4. SECONDARY PARENT/LEGAL GUARDIAN CONTACT INFORMATION 4b. Relationship 4c. Address 4e. State 4f. Zip Code + 4 4g. Day Phone 4h. Evening Phone 4i. E-Mail Address 5. EMERGENCY CONTACT INFORMATION (will be contacted in case primary or secondary contacts are unreachable in case of an emergency) 5b. Relationship 5c. Address 5e. State 5. Zip Code + 4 5g. Day Phone 5h. Evening Phone 5i. E-Mail Address 6. MEDICAL INFORMATION 6a. Medical Insurance Provider Name 6a. Medical Insurance Policy Number 6c. Medical Insurance Provider Address 6d. Medical Insurance Provider Phone 7. DEMOGRAPHICS 7a. Ethnicity 7b. Community Profile NSCADM 001 (Rev 03/12) CADET APPLICATION 8. PARENT/LEGAL GUARDIAN AGREEMENT & CONFIRMATION
I hereby consent to my child/ward enrolling in the Naval Sea Cadet Corps (NSCC)/Navy League Cadet Corps (NLCC). I understand that the NSCC/NLCC is organized along military lines and that NSCC/NLCC regulations govern my child's/ward's membership and that violation of regulations may result in my child's/ward's discharge from the NSCC/NLCC. I will ensure that my child/ward abides by all regulations and lawful orders from superior officers and cadets. I certify that, to the best of my knowledge, he/she is physically and mentally fit to take part in vigorous activities or if not, I have disclosed all physical/medical/disability limitations and he/she is not suffering from any communicable disease. I further agree to be responsible for the value of any uniforms and/or equipment loaned him/her, reasonable wear and tear expected. I understand that such uniforms or equipment shall remain the property of the Naval Sea Cadet Corps while on loan, and I agree to return them when my child/ward ceases to serve as a cadet, or at any other time upon request of a Naval Sea Cadet officer or other authorized agent I have been briefed on the NSCC medical insurance plan. I am aware this is an accident/illness “excess” policy and that the limit of the policy is a total of $25,000 for all accidental benefits/$5,000 for illness with no deductible. I understand that my personal medical insurance is the primary policy, but in the event that I do not have insurance and/or the NSCC policy limits are exhausted, I understand that I am responsible for all medical payment above $25,000 for accidents/$5,000 for illnesses. I also understand that payment of enrollment fees will be required ANNUALLY, and payment of uniform fees may be required upon enrollment. I agree to be bound by all NSCC regulations, policies, and amendments thereof that govern my child's/ward's membership and conduct; I further waive any right to challenge in any way any determination made by the NSCC/NLCC regarding my child's/ward's continuance of membership in the NSCC/NLCC should he/she violate said regulations.
8a. Signature of Parent/Legal Guardian 8b. Date (DD MMM YY) 8c. Signature of Witness (Unit CO or other designated officer) 9. STANDARD RELEASE
I, being the parent/legal guardian of a member of the U.S. Naval Sea Cadet Corps (NSCC)/U.S. Navy League Cadet Corps (NLCC), in consideration of his/her acceptance and continuance of membership in the NSCC/NLCC, I hereby release from any and all claims, demands, actions, or causes of action due to death, injury or illness the following: (1) the government of the United States of America and all its departments and agencies; (2) any jurisdiction (state, county, city, town, district or other political subdivision) where official NSCC/NLCC activities take place; (3) the Navy League of the United States; (4) any organization or association, public or private, that sponsors NSCC/NLCC activities; (5) the NSCC/NLCC; (6) all officers, representatives, and agents, acting officially or otherwise of the previously mentioned, jurisdictions, organizations, and associations. I hereby acknowledge that I have received and reviewed the Nationwide Life Insurance Company Specified Hazard Group Insurance Certificate for the United States Naval Sea Cadet Corps (NSCC) (Policy 502-95-21736). I consent to the examination of my son/daughter/ward by the medical facilities of the Department of Defense (DOD), U.S. Coast Guard (USCG), National Oceanographic and Atmospheric Administration (NOAA), U.S. Public Health Service (USPHS), or civilian physicians/medical facilities to determine physical status for participation in the NSCC/NLCC. I further authorize, as may be required treatment in said facilities in the event of any illness or accident arising aboard DOD, USCG, or NOAA facilities or vessels, or during other authorized NSCC/NLCC activities. This consent includes any medical, anesthesia, or surgical treatment or hospital services rendered under the general and/or special instructions of the attending physician or other physicians assigned his/her care. This consent does not include major surgery unless, in the medical opinion of two physicians, it is reasonably necessary to save life, or where second opinions are similarly impracticable the concurring opinions of other physicians may be excused. I also grant permission for my son/daughter/ward to be transported as a passenger in military aircraft, vessels and vehicles. I consent to the taking of any pictures of my son/daughter/ward through photographic, cinematic, and digital media, and to the reproduction and/or publication of same by any photographic facility of the NSCC/NLCC, DOD, USCG, NOAA, NLUS, and the media/press. I consent to the use of said pictures in connection with education programs or promotional activities of the said organizations. This standard release shall remain in effect for the duration of my son’s/daughter’s/ward’s membership in the NSCC/NLCC. I also give my permission for facsimiles of this release to be made, and when presented by an authorized official of the NSCC/NLCC, DOD, USCG, NOAA shall be considered as valid as the original signed by me.9a. Cadet Full Name 9b. Social Security Number 9c. Parent/Guardian Name (Print of Type) 9d. Parent/Guardian Signature 9e. Date (DD MMM YY) 9f. Name of Witness (Unit CO or other Designated Officer - Print or Type) 9g. Signature of Witness (Unit CO or Designated Officer) 9h. Date (DD MMM YY) UNIT USE – DO NOT WRITE BELOW THIS LINE ENROLLMENT DISENROLLMENT Cadet Application (NSCADM 001) ID Card Returned Medical History (NSCADM 020) Uniforms Returned Medical Exam (NSCADM 021) NRTCs Returned Enrollment Fees Collected Deposit Refunded Uniform Fees Collected NSCADM 009 to NHQ Uniforms Issued Reason for Disenrollment
Enrollment (NSCADM 007) to NHQ NSCADM 001 (Rev 03/12), Reverse U.S. NAVAL SEA CADET CORPS REPORT OF MEDICAL HISTORY U.S. NAVY LEAGUE CADET CORPS AUTHORIZATION, CONSENT AND RELEASE
Upon enrollment, the information requested below is required to provide the medical examiner an accurate history of illnesses and injuries that may affect the applicant's ability to perform the strenuous physical exercise and exposure to living and working environments that are a part of the NSCC/NLCC training program. Also this information will be provided to medical examiners in case of injury or illness while participating in NSCC/NLCC activities. If taking medications at time of enrollment, list in Block 9.
THE INFORMATION YOU PROVIDE MUST BE ACCURATE AND COMPLETE. You are encouraged to consult your private medical provider regarding past illnesses. Proof of immunization for polio, measles, mumps, rubella hepatitis B, pertussis and tetanus plus diphtheria and Menactra vaccine for Meningitis must be attached.
After enrollment, use this form to screen cadets for continued medical fitness before sending to Orientation, Recruit, Advanced and/or other trainings. Commanding Officer’s (CO) and Commanding Officers of Training Contingents (COTC) retain the obligation to deny acceptance for enrollment or training to any cadet if upon review of this form, it is determined that the cadet is not physically/medically qualified for participation unless Medical Condition and/or disability accommodation per ADA guidelines has been requested and approved.
1. UNIT INFORMATION 1a. Unit Name 1b. Region 2. PERSONAL INFORMATION 2a. Last Name 2b. First Name 2d. Social Security Number 2f. Date of Birth (DD MMM YY) 2h. Parent/Guardian Name (cadets only) 2i. Home Address 2k. State 2l. Zip Code + 4 2m. Home Phone 2n. Date of Physical Examination (DD MMM YY) 3. MEDICAL PROVIDER/INSURANCE INFORMATION 3a. Medical Insurance Provider Name 3b. Medical Insurance Policy Number 3c. Medical Insurance Provider Address 3d. Medical Insurance Provider Phone 3e. Medical Provider Name 3f. Medical Provider Phone Number 4. MEDICAL HISTORY (Mark each item “YES” or “NO” Every item marked YES must be fully explained in block 9: explain treatment to return cadet to medically fit for NSCC) HAVE YOU EVER HAD OR DO YOU NOW HAVE ANY OF THE FOLLOWING CONDITIONS: 4a. Tuberculosis or live with someone with tuberculosis
4n. Head injury or concussion 4b. Chronic or recurrent abdominal or stomach pain
4o. Seizures, convulsions, epilepsy, or fits 4c. Asthma or breathing problems related to exercise, pollen, etc.
4p. Car, train, sea, and/or air sickness 4d. Been prescribed or use an inhaler
4q. A period of unconsciousness 4e. Loss of vision in either eye
4r. Heart trouble or murmur 4f. Loss of hearing or wear a hearing aid
4s. Received counseling for emotional or behavior disorder 4g. Impaired use of arms, legs, hands, feet
4t. Eating disorder (bulimia, anorexia) 4h. Knee problems
4u. Sleepwalking 4i. Broken bones(s) (cracked or fractured)
4v. Bedwetting 4j. Diabetes
4w. Been hospitalized (if yes, why, when, where) 4k. Anemia (including sickle cell)
4x. Any illness or injury not mentioned above (if yes, explain) 4l. Dizziness or fainting spells (including after exercise)
4y. Advised to avoid certain physical activities (if yes, explain) 4m. Frequent or severe headaches
4z. FEMALES ONLY: At what age did you begin menstrual cycle: NSCADM 020 (REV 05/09) REPORT OF MEDICAL HISTORY 5. IMMUNIZATION RECORDS (attach copy of immunization record to this form) 5a. Date of last tetanus or booster 5b. Date of Menactra Vaccine for Meningitis 5c. Date of negative PPD or Medical Provider Clearance for TB 6. ALLERGIES (Mark each item “YES” or “NO” Every item marked yes must be fully explained in block 9.) DO YOU NOW HAVE ANY OF THE FOLLOWING ALLERGIES: 6a. Bee or Wasp Sting
6e. Latex 6b. Hay Fever or seasonal allergies
6f. Any drug, E-mycin antibiotic, or sulfa allergies, list in Block 9 6c. Insect Bites
6g. Other Allergies, list in Block 9 6d. Iodine/seafood
6h. Food allergies, list in Block 9 6i. Describe the allergic reaction and what condition occurs: (Include comment if mild or seasonal, or life threatening requiring immediate medical attention) 7. OVER THE COUNTER MEDICATIONS (for NLCC orientation, NSCC recruit, and Advanced Training. NOT Unit Drills. 7a. Over the Counter (OTC) medications that may be administered at training evolutions by our staff when requested, for these conditions:
Cough Medicine (Robitussin DM, Dimetapp, etc.), Throat/Cough Drops (Chloraseptic, Halls, etc.), Decongestant (Sudafed, etc.)
Milk of Magnesia, Dulcolax, Ex-Lax, or Glycerin Suppository
Bacitracin ointment, Betadine, Neosporin ointment
Pepto Bismol, Kaopectate, Immodium AD , etc.
Tylenol or Ibuprofen (Motrin, Advil, Aleve)
Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil, Aleve)
Calamine Lotion, Topical Lidocaine Spray or Aloe Vera Gel
Bacitracin ointments, Betadine, Neosporin Ointment
Other medications not listed above may be administered if so recommended by qualified medical staff. Parents will be contacted directly when over the counter medications need to be administered during unit drills 8. STATEMENT OF UNDERSTANDING AND CONSENT
BY INITIALING YOU CERTIFY YOUR UNDERSTANDING & CONSENT TO THE FOLLOWING PARAGRAPHS:
8a. I understand that all medications will be administered to the cadet based on dosing instructions on the medication bottle/package. In no instance will cadets be allowed to self-medicate with any over the counter medication. 8b. I understand and consent that these written instructions may be superseded if, in the opinion of a medical provider, not doing so would place the cadet in a medically compromised condition. 8c. If you do not want your child to be administered over the counter medications, or certain medications concurrent with other medications, use Block 9 to specify those medications or write, “Do not medicate my child with any over the counter medications”. 9. REMARKS (please include comments as required by Blocks 4, 6, and/or 8. Also provide any other medical history that you or your physician deems important) 10. AUTHORIZATON AND RELEASE
I certify that to the best of my knowledge that the information provided is true and accurate and that I have disclosed all pertinent medical history. Furthermore, I authorize the Naval Sea Cadet Corps, its agents, officials, and training staff members, to dispense medication listed on this Authorization. I “Hold Harmless” the Naval Sea Cadet Corps from any and all liability, actions, or causes of action for damages or injury that may arise, directly or indirectly, from my son/daughter’s use of medication while participating in Naval Sea Cadet Corps Activities. I understand that training staff members may not be medical professionals and that medication will be dispensed according to the manufacturer’s instructions and/or the instructions I provided on this authorization.
10a. Parent/Guardian (for cadets) or Member Name (Type of Print) 10b. Signature 10c. Date (DD MMM YY) NSCADM 020 (REV 05/09), Reverse U.S. NAVAL SEA CADET CORPS U.S. NAVY LEAGUE CADET CORPS REPORT OF MEDICAL EXAM INSTRUCTIONS
Acceptance criteria for applicants the Naval Sea Cadet Corps/Navy League Cadet Corps (NSCC/NLCC) are listed on the reverse side. No one will be denied admission to the program due to a medical disability, however participation may be limited if the cadet is not able to meet the medical standards necessary to FULLY participate in training activities involving strenuous physical exercise and activities such as orientation in fighting shipboard fires in often hot and humid environments. The examiner should list any condition(s) that could interfere with full, unrestricted, participation in the NSCC/NLCC. Conditions that will or are likely to require treatment particularly unresolved injuries and recurrent illness must be listed. The history of immunization should be verified to the satisfaction of the medical examiner. A licensed medical provider must complete this examination.
1. UNIT INFORMATION 1a. Unit Name 1b. Region 2. PERSONNEL INFORMATION 2a. Last Name 2b. First Name 2d. Social Security Number 2f. Date of Birth (DD MMM YY) 2h. Parent/Guardian Name (cadets only) 2i. Home Address 2k. State 2l. Zip Code + 4 2m. Home Phone 2n. Date of Physical Examination (DD MMM YY) 2o. Location of Physical Examination Anatomy Normal Abnormal NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment) 4a. Head, Face, Neck, and Scalp 4c. Sinuses 4d. Ears – General (Internal and External Canals) 4e. Drum (Perforation) 4f. Eyes- General 4g. Ophthalmoscopic 4h. Pupils (Equality and Reaction) 4i. Heart (Thrust, Size, Rhythm, and Sounds) 4j. Lungs and Chest 4k. Abdomen and Viscera (Include Hernia) 4l. External Genitalia (Genitourinary) 4m. Upper Extremities 4n. Lower Extremities 4p. Spine and other Musculoskeletal 5. LABORATORY FINDINGS (only required for those with a history of urinary tract infections or anemia, enter N/A if tests were not administered) 5a. Urinalysis 5b. Blood (1) Albumin: (2) Sugar: (1) Hemoglobin: (2) Hematocrit: 6. MEASUREMENTS AND OTHER FINDINGS 6a. Height 6b. Weight 6c. Obese 6d. Pulse 6e. Blood Pressure (1) Systolic: (2) Diastolic: 6f. Audiogram (if available) 6g. Wears Glasses 6h. Wears Contacts 6i. Uncorrected Vision HZ 500 1000 2000 3000 4000 6000 Yes No (1) Left: 20/ (2) Right: 20/ 6k. Color Vision 6l. Other Findings (if more room is needed, continue on reverse) NSCADM 021 (REV 05/09) REPORT OF MEDICAL EXAM 7. CLINICAL SCREENING (Please check if the patient has any of the following conditions and whether it will affect the ability to participate in NSCC/NLCC activities.) Condition(s) Pre-Existing NOTES: (Describe every condition in detail. Enter pertinent item number before each comment) 7a. Seizure or convulsion disorder 7b. Asthma 7c. Symptomatic/recurring orthopedic injury 7d. Diabetes, Type I 7e. Diabetes, Type II 7f. Hypersensitivity to Food 7g. Insect bites/stings sensitivity 7h. Head injuries resulting in residual impairment 7i. Neurological Impairment 7j. History of recurring loss of consciousness 7k. History of debilitating motion sickness 7l. Sleepwalking 7m. Bedwetting 8. NOTES, REMARKS, AND OTHER FINDINGS (Use additional sheets of paper if needed) 9. MEDICAL PROVIDER ENDORSEMENT (Check all that apply):
I have reviewed the data above, reviewed the patient’s medical history form and make the following recommendations for his/her participation in the NSCC/NLCC
CLEARED WITHOUT RESTRICTIONS
Cleared AFTER further evaluation or treatment for:
Cleared for LIMITED participation NOT CLEARED FOR PARTICIPATION OTHER RECOMMENDATIONS
Recommend close monitoring during conditioning because of weight/fitness/other.
Recommend restrictions or monitoring of weight loss/gain or fitness concerns.
Recommend participations under following condition(s):
10. MEDICAL PROVIDER 10a. Name of Medical Provider (Type or Print) or Medical Provider Stamp 10b. Signature (MD, DO, PN, PA) 10c. Date (DD MMM YY) 10b. Medical Provider Address 10c. City 10c. State 10c. Zip Code +4 10c. Phone NSCADM 021 (REV 05/09), Reverse U.S. NAVAL SEA CADET CORPS U.S. NAVY LEAGUE CADET CORPS PARENT SUPPORT QUESTIONNAIRE
The adult leadership of the NSCC/NLCC is made up entirely of volunteers. Many are parents just like you. Now that your child is joining our program, we ask you to please look over this questionnaire to see if you might be able to help out in some way.
o Yes, I am willing to help out the unit with the following:
o Volunteer as a uniformed adult leader (must meet weight requirements) o Volunteer as a non-uniformed adult leader o Join a Parent’s Auxiliary Group o Provide transportation for unit activities o Chaperone unit activities o Assist with unit recruiting o Assist with unit fundraising o Assist with unit morale activities (outings, picnics, dances, etc.) o Assist with unit administrative functions (copying, typing, etc.) o Assist with unit supply (issue uniforms, maintaining inventory) o Become a member of the Navy League of the United States or Sponsoring Organization o Make the NSCC a beneficiary of my Combined Federal Campaign contribution (CFC #10185) (Federal and Military Employees only) o Commit to an annual donation to the unit of $ ___________
If you can offer assistance with anything else that is not listed above please let us know:
Cadet Name (Last, First, MI Type or Print) NSCADM 004 (Rev 08/03)
Ethic’s Committee Prague 2011 – ERA EDTA Congress Ethic’s Committee The public, clinicians, nurses, associates involved in nephrology care grant local, national and international medical profession leadership considerable discretion in setting its own standards because they trust that their leaders will place patients interests ahead their own or those of third parties. Ethic
Platts 27th Annual Global Power Markets (Agenda subject to change) DAY ONE: Sunday, April 1, 2012 6:30 - 8:00 p.m. Pre-registration 7:00 – 8:00 p.m. Welcome Reception — Hosted by Winston & Strawn DAY TWO: Monday, April 2, 2012 7:30 a.m. Registration and Breakfast — Hosted by Wells Fargo 8:45 a.m. Welcome and Opening Remarks Jim