LLA Summer Camp PO Box 151115, Ely, Nevada 89315 Phone: 702-456-9664 Fax: 888-742-7316 Email: mail@leadershipchallengecamp.com AFJROTC LLA Summer Camp Enrollment Application Last Name First Name Social Security# Birth Date Age Sex Address City State Zip Parents Name Parents Home Phone Parents Work Phone Parents Cell/Pager Cadet s Email School Grade LIST ANY PHYSICAL LIMITATIONS, DISABLITIES OR RECENT INJURIES AND CURRENT MEDICATIONS: AFJROTC LLA Summer Camp 31 July - 2 August 2013 Camp is located at the Rapport Executive Retreat, Alamo, NV Camp Office Phone: 775-725-3861 Health Insurance Information Provider: Policy#: Group#: Agent: Agent's Phone: Cancellation Policy The philosophy of the Leadership Challenge Camp is playing to win. One of the important principles taught at Leadership Challenge Camp is commitment. Signing this enrollment form represents a commitment by you and your parents to attend this Leadership Challenge Camp. If you cannot attend this Leadership Challenge Camp, you must notify your JROTC Unit Commander at least 72 hours before departure or your enrollment fee will become non-refundable. Failure to do so will prevent another deserving cadet taking your place at camp, and you may not be offered this opportunity again. Parent s Signature: Cadet s Signature: CAMP EMERGENCY TELEPHONE NUMBERS: 928-773-3297 or 702-498-0114 YOU MUST ALSO SIGN THE ACTIVITY RELEASE FORM Liability and Accident Insurance Coverage Through DHC Insurance Underwritten by Berkley Life and Health Insurance Company V 04.26.13
ACTIVITY RELEASE FORM ANY PARTICIPANT, VOLUNTEER, CHAPERONE, GUEST OR STAFF MUST COMPLETE THE FOLLOWING ACTIVITY RELEASE FORM BEFORE YOU MAY BEGIN YOUR ACTIVITIES IN OR ABOUT THE PREMISES DESCRIBED BELOW. (Please keep a copy of this form within each members file for future reference) Although the management and staff of Leadership Challenge, LLC and the Air Force JROTC Program have taken reasonable measures to ensure that you will have a safe and enjoyable educational experience at Leadership Laboratory Activity Summer Camp, you must be aware that you will be engaging in mentally, emotionally and physically challenging events, all of which contain a certain element of risk of mental or emotional upset, physical injury or disability. Leadership Laboratory Activity Summer Camp includes a series of activities including mentally and emotionally challenging seminars, warm-ups, games, team building, and team and individual competitions. Some events include additional rigorous physical activities such as lifting, climbing, balancing, spotting and repelling. Most of these activities can be mentally, emotionally, and physically challenging and demanding. However, these activities are designed to be well within the capability of any MCJROTC Cadet who is in reasonably good heath, mental, emotional and physical condition. All activities are presented on a "Challenge by Choice" basis. This means that participants choose their own level of participation. Although, safety is a very high priority for each event, there is an inherent risk which must be assumed by each participant that he or she may suffer a mental or emotional upset or physical injury. If you have certain pre-existing conditions, your participation in some of the activities may not be recommended. It is your responsibility to share any such pre-existing or limiting personal conditions with the camp management and/or staff before each event. Each participant at Leadership Laboratory Activity Summer Camp is required to be responsible for their own safety and should have health/accident insurance coverage and/or be personally responsible for any and all medical costs they may incur during or after their Leadership Laboratory Activity Summer Camp experience. In the final analysis, you are ultimately responsible for your own safety. By signing this Activity Release Form, you hereby agree to follow the directions of the instructors of the Leadership Laboratory Activity Summer Camp for your own safety. RELEASE / DISCLAIMER I do hereby assume full responsibility for any and all damages, injuries (including death), or losses that I may sustain or incur, if any, while attending, engaging, practicing, participating or witnessing activity and/or certain event(s) occurring in or about Rapport Executive Retreat, or at any offsite location (Premises). I hereby assume full risk, waive all claims, and release and hold the instructors, chaperones, staff, and volunteers, of Leadership Challenge, LLC and the Air Force JROTC Program, individually or otherwise, harmless for any and all liability, claims, suits, damages, expenses, fees, actions, or rights of action or judgments as a result of injury or death to myself or members of my family or heirs, or my guests, or damage, destruction or loss to my property, which in any way relates to, arises out of, or is in any way connected with my presence on the Premises, or my participation in events or activities thereon, or the negligent acts or omissions of the releasees or any other third party. I agree to wear all protective equipment required while participating in the activity (i.e. safety helmet), and I am fully aware and understand that releasees do not have on or about the premises provisions for ordinary or emergency medical services, nor do they employ or contract with any medical services. In the event off-site professional medical care is necessary, I authorize treatment of my minor child and the release of medical records and billing information to Leadership Challenge, LLC and the Air Force JROTC Program for the purposes of them filing for insurance reimbursement. In consideration of my participation in and the use of the Premises or facilities, I hereby release and covenant not to sue the owners of the Leadership Challenge, LLC or the Premises (releasees), instructors, chaperones, staff, volunteers, shareholders, directors, officers, employees, representatives, agents, affiliates and lessees from any and all claims resulting from any injury, of any type, that may occur to me while participating in the Leadership Laboratory Activity Summer Camp. PARENT OR GUARDIAN MUST SIGN IF PARTICIPANT IS UNDER 18 YEARS OF AGE. PARENTAL/LEGAL GUARDIAN CONSENT I HAVE READ AND FULLY UNDERSTAND THE ABOVE RELEASE/WAIVER AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS WAIVER VOLUNTARILY. Signature: Date: Printed Name: Relationship: Photo Release: I understand that photos or video may be taken during Camp. I hereby authorize the use of my, or my child s, image for use in promoting Leadership Challenge, LLC, and the Air Force JROTC Program. Parent s Initials: Student's Signature: Date: CAMP EMERGENCY TELEPHONE NUMBERS: 1-702-498-0114 1-775-725-3861
PO Box 151115, Ely, Nevada 89315 Phone: 702-456-9664 Fax: 888-742-7316 Email: mail@leadershipchallengecamp.com AFJROTC LEADERSHIP LABORATORY SUMMER CAMP Required Participant Equipment List The following clothing, equipment and personal items are required for ALL participants attending AFJROTC Senior Leadership Course Summer Camp [ ] AFJROTC Utility Uniform - BDUs (1 complete set, boots preferred, sneakers optional) [ ] Underwear & boot socks (4 changes required) [ ] Sweat gear (top and bottom) (for sleep wear, night watch & cold weather) [ ] Gloves (Work Gloves NO MITTENS) [ ] Canteen (Canteen or 20 oz plastic bottle of water additional Water & Gatorade will be provided) [ ] Toiletries (Deodorant, toothbrush, tooth paste, grooming aids required, hand and bath soap, bath towel) [ ] Rain Poncho (Single use plastic poncho OK) [ ] Sunblock (Spf 30 or higher recommended) [ ] Flashlight (Ordinary flashlight with fresh batteries) [ ] Sleeping Bag, Pillow, & Bath Towel [ ] Pocket Notebook & Pen (3 X 5 Spiral Lined Pocked Notebook, Blue or Black Ink Pen No Pencils) Cadets may bring cell phones to camp, however, they will be collected for safe keeping. Cadets wishing to take pictures at camp will need to bring a camera. Candy, Magazines, Radios, Music Players, Tobacco Products, Alcoholic Beverages, Controlled Substances (unless prescribed) and Weapons are not permitted! I have assembled all of the required items listed above as checked, and I am fully prepared for AFJROTC LLA Summer Camp. Student Signature Parent s Signature
Cadet Conduct Agreement 1. I WILL BE ON TIME FOR ALL FORMATIONS, EVENTS AND DUTY ASSIGNMENTS. ON TIME MEANS I WILL HAVE ALREADY ARRIVED! 2. I will take complete responsibility for my actions, results and outcomes while here at LLA Summer Camp. 3. I will refrain from making excuses for my mistakes, failures and disappointments while here at LLA Summer Camp 4. I will refrain from blaming others for my mistakes, failures and disappointments while here at LLA Summer Camp. 5. I will be a team player and I will support my fellow team members to do the very best they can during all work details and events while here at LLA Summer Camp. 6. I will be in the full uniform of the day, all of my gear will be properly stowed, and my room and head will be clean and neat at all times during the day. 7. I will care for the facilities I am using while at LLA Summer Camp, and I will leave them in better condition than I found them when I depart. 8. I will be aware of and follow the posted Plan of the Day, and all orders given to me by the Instructors, and support staff, while here at LLA Summer Camp. 9. I will stand my watch in a military manner and follow the camp Standing Night Watch Orders, the orders of Junior Watch Officer, and the Watch Officer. 10. I will request permission before entering the berthing area of another, and only enter when permission has been granted. I will never under any circumstance enter the berthing area occupied by cadets of the opposite sex unless ordered to do so and accompanied by a camp instructor. 11. I understand that I may not set foot out of my assigned berthing area after lights out except when on watch, or in an emergency, and then only with the permission of the Junior Watch Officer. 12. I understand that I may opt out of any event before it starts at LLA Summer Camp, however, if I opt in I must complete that event to the best of my ability. 13. I will have my Water, Cover, Gloves, Sun Block, Gold Card, Cadet Record Book, Pen and this Conduct Agreement on my person at all times while here at LLA Summer Camp. I will apply sun block in the morning and again in the afternoon before outside events. I hereby agree to keep all of the above agreements to the very best of my ability. Agreed to this Day of 2013 Cadet Signature Your signature on this document makes this a legally binding agreement.
Cadet Orientation Flight Release, Indemnity, and Assumption of Risk Air Force Reserve Officer Training Corps and the Civil Air Patrol will arrange for and provide a Cadet Orientation Flight activity. The purpose of the activity is to introduce the cadet to basic flight procedures to include straight and level flight, turns, constant rate turns, basic aerial navigation procedures, and traffic patterns. The academic (ground) phase of instruction will include basic flight planning procedures, aerodynamics, aircraft structures, and aviation safety procedures. Name of Child: Detachment / School By signing below, I grant permission for my child to participate in the Activities described above. This release, Indemnity and Assumption of Risk Statement covers all events associated with the Activities. If I have any concerns about my child s ability to participate, I agree to discuss my concerns with my child s instructor or, if appropriate, with my child s physician before signing this form. I agree to assume the risk that unexpected events may occur and result in harm, injury or illness to my child or damage to my property or my child s property while my child is participating in or observing the Activities, or traveling to or from the Activities. I agree, on my behalf and on behalf of my child, to indemnify Air Force Reserve Officer Training Corps, and the Civil Air Patrol and each of their employees, agents, affiliates, successors and assigns (collectively, the Indemnified Parties ) and not to sue the Indemnified Parties for any harm or damage associated with my child s participation, observation, or travel if the harm or damage is not due to the negligence or fault of any of the Indemnified Parties. I understand that my child s participation in these Activities is voluntary. If my child requires emergency medical treatment, please contact: Name of Emergency Contact Person: Home Phone: Work Phone: If the Emergency Contact Person I have listed is not available, please contact: Doctor: Phone: I consent to the provision of emergency medical treatment for my child to the extent that the treatment is necessary in the medical opinion of the doctor rendering the treatment. Signature of Parent or Legal Guardian: Date:
AFJROTC PHYSICAL HEALTH SCREENING QUESTIONNAIRE To The Cadet and Parent/Guardian: It is mandatory to complete this screening form prior to participating in the Cadet Physical Training (PT) Program. Return this completed questionnaire to your SASI or ASI, and advise them if you responded yes to any of the questions below. 1. Has there been any significant change to your health in the past 6 months? YES - NO 2. Are you currently on a medical profile exempting you from PT activities? YES - NO 3. Has a physician ever indicated you have heart disease, heart or breathing troubles? YES - NO a. Do you suffer from pains in your chest, especially with physical activity? YES - NO b. Do you feel faint or have dizzy spells during or after physical activity? YES -NO c. Do you have shortness of breath related to asthma or any other condition YES - NO that exercise could aggravate? 4. Have you experienced a significant weight change in the past 6 months? YES - NO a. If Yes, indicate the estimated amount gained or lost: lbs. 5. Have you ever been diagnosed or displayed symptoms of heat stress? YES NO 6. Do you take any dietary, herbal or nutritional supplements, which contain any of the following substances: Ephedra/Ephedrine, Guarana, Phenylephrine, Pseudoephedrine? YES - NO a. If Yes, please list: 7. Do you have any other medical issues that may cause a safety concern during YES - NO physical exercise? a. If Yes, please list: (Printed Name of Cadet) (Signature of Cadet) (Date) (Printed Name of Parent/Guardian) (Signature of Parent/Guardian) (Date) The Privacy Act of 1974 applies. The sole purpose of this form is to gather information to be used for screening a candidate for participation as an AFJROTC cadet in the AFJROTC Physical Training (PT) Program. This form is for internal use only. Disclosure is voluntary; failure to disclose will result in the inability to participate in PT activities.
Washington County School District Parent/Guardian Field Trip Permission Form And Emergency Contact Information Dear Parent/Guardian, During the 2013-2014 School Year, your child may be involved in multiple field trip activities with AF JROTC. Your signature below indicates your consent for you child to participate. It also indicates that if any injury occurs that the school will make reasonable efforts to contact you, and that you give permission, in the event of injury, for your child to receive emergency medical aid, anesthesia, and/or an operation if, in the opinion of the attending physician, such treatment is medically necessary. You also agree to allow your child s picture to be taken during these trips or during school activities and used in our in-house newsletter and public website (dixiejrotc.org). Cadets must meet academic eligibility requirements as stated in the Cadet Handbook. Please complete the remainder of this form and return it to the Aerospace Science Instructors as soon as possible. I, the parent (s)/guardians of Cadet do hereby grant permission for my son or daughter to attend JROTC field trips during this school year. I also grant permission for my child to use school district or Air Force transportation to attend these field trips and for photographs of my child to be used in the JROTC publications, including the school website. (Signature of Parent(s) or Guardian(s)) (Date) (Printed name of Parent(s) or Guardian) In case of an emergency contact Phone number Insurance Company Policy Number Form 1014 Revised 26 July 2011
Cadet Medication Form Over Night Trips Only 1. Only send the amount of medication needed for the time of the trip. *(You may want to send 1 day extra just for emergencies) 2. Medication needs to be clearly labeled as to what it is. Do not combine multiple pills in the same bottle. 3. Do not send weekly flip open pill containers. 4. Put all medication in a re- sealable gallon sized bag with this form inside. Cadet s Name Parent s Name Phone# Physician s Name Phone# Medication Name Dosage Time of Day Comments: We want your cadet to have the best possible experience. Please be as thorough as possible on this form. If there were to be a medical emergency we want to be able to provide the caregivers with the best information possible. Over The Counter Medication OTC medications will not be given to cadets without parent permission. If you would like to give consent for your cadet to be given OTC medications as needed please specify which medications and sign and date the bottom of this form. Parent Signature Date This form will only be seen by the Chaperone put in charge of administering the medication for the specified trip. The bag containing the form and medication will be given to the cadet upon our return to the JROTC Building.