Microsoft word - nscadm00

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)

Source: http://www.gulfeagledivision.org/images/Enrollment_Forms.pdf