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POJU<WW4{j k}0}j8Z88@'k8x'k^VVV||\TVVV}VVVV!<<(((((( APPLICATION FOR NEW YORK WING ENCAMPMENT & ACADEMIESNAME (Last Name, First Name, Middle Initial)  FORMTEXT       JOINED CAP: MMM YY  FORMTEXT       CAPID  FORMTEXT      YR of Activity  FORMTEXT      CAP GRADE  FORMDROPDOWN WING  FORMTEXT    UNIT CHARTER NUMBER  FORMTEXT      ENCAMPMENT LOCATION  FORMTEXT       MAILING ADDRESS (Number and Street)  FORMTEXT      Applying As: Basic Cadet FORMCHECKBOX  Cadet Staff FORMCHECKBOX (City)  FORMTEXT      (State)  FORMTEXT    (Zip Code)  FORMTEXT       -  FORMTEXT      Senior Staff FORMCHECKBOX  Other* FORMCHECKBOX This is my first encampment FORMCHECKBOX DATE OF BIRTH: DD MMM YY  FORMTEXT      GENDER  FORMDROPDOWN  SOCIAL SECURITY NUMBER (Required)  FORMTEXT     -  FORMTEXT    -  FORMTEXT     * If applying for an advanced academy (i.e., Flight Academy  Powered, Flight Academy  Glider)  enter the name of the activity here. Otherwise leave blank. FORMTEXT      RELIGIOUS PREFERENCE  FORMTEXT      PRESENT OCCUPATION  FORMTEXT      ARE YOU INTERESTED IN ATTENDING RELIGIOUS SERVICES? YES  FORMCHECKBOX  NO  FORMCHECKBOX (Home Phone):  FORMTEXT      E-MAIL ADDRESS  FORMTEXT      (Business Phone):  FORMTEXT      T-SHIRT SIZE (Required)  FORMDROPDOWN CPPT (18 and Older Only): Completed Will be completed prior to encampment  FORMCHECKBOX   FORMCHECKBOX (Cell Phone):  FORMTEXT      Special Meals Required:  FORMCHECKBOX  What kind?  FORMTEXT       (Special meals may not be able to be accommodated) SENIORS ONLY: Full-Time  FORMCHECKBOX  or Part-Time  FORMCHECKBOX  Part-Time Dates:  FORMTEXT      Check the statement that best reflects your experience in each of the two categories of flight: 1. Single Engine Aircraft Flight Experience (Cadets Only): Have never flown in a single engine plane (0) CAP Orientation Flight Back Seat Only (1) CAP Orientation Flight Front Seat "Flew the airplane" (2) Had additional flight training or student pilot (3) Ineligible to fly (over 18 at time of encampment) (x) Do not want to fly in a small aircraft (x)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Weight (cadets only - for flight planning purposes): FORMTEXT     2. Flight Experience in Military Aircraft (i.e., C130, etc.) (Cadets & Seniors):  Have never flown in a military aircraft (0) Have flown once in a military aircraft (1) Have flown more than once in a military aircraft (2) Do not want to fly in a military aircraft (x)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX PAYMENT OF ENCAMPMENT FEES:I have included payment of $  FORMTEXT       in the form of:Cash:  FORMCHECKBOX  Check:  FORMCHECKBOX  Money Order:  FORMCHECKBOX  Credit Card:  FORMCHECKBOX If Paying by Credit Card Visa  FORMCHECKBOX  MasterCard  FORMCHECKBOX  Account Number  FORMTEXT       Expiration Date: (MMM YY)  FORMTEXT       Name on Credit Card:  FORMTEXT       Signature of Card-holder NYWF31 (12JAN08) Page 1 of 3 CONTINUE ON TO NEXT PAGE CIVIL AIR PATROL RELEASE AGREEMENT (ALL MUST SIGN)KNOW 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 (CADETS ONLY)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 FATHERS SIGNATURE FATHER OR LEGAL GUARDIAN WITNESS FOR MOTHERS SIGNATURE MOTHER OR LEGAL GUARDIANSQUADRON CERTIFICATION I certify that the applicant is a member in good standing in my unit and I approve his/her request. SQUADRON COMMANDERWING CERTIFICATION (Required for applicants who are not members of New York Wing) This applicant has my permission to attend the NYWg Encampment/Academy.  WING COMMANDER NYWF 31 (12JAN08) Page 2 of 3 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.NAME OF PARTICIPANT (Last Name, First Name)  FORMTEXT       CAPID  FORMTEXT      DO YOU CURRENTLY USE ANY MEDICATION? 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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 Company  FORMTEXT       Policy Number  FORMTEXT       EMERGENCY ADDRESSEE - 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