NAVAL JUNIOR RESERVE OFFICERS TRAINING CORPS

(NJROTC)

STANDARD RELEASE/MEDICAL EMERGENCY FORM

Date: _____________________

I, _______________________________________, being the legal parent/guardian of 

__________________________________________, a member of the Naval Junior Reserve Officers Training Corps, in consideration of the continuance of his/her membership in NJROTC and/or his/her acceptance for NJROTC training, do hereby release from any and all claims, demands, actions, or causes of action, due to death, injury, or illness, the government of the United States and ll its officers, representatives, and agents acting officially or otherwise and also the local, regional, and national Navy officials of the Unites States, and the U.S. Naval Reserve Officers training Corps and its officers and officials.

I hereby authorize personnel of the Department of Defense, Armed Forces, Public Health Service, or civilian physicians to render such medical and dental care as may be necessary and medically indicated in the case of my son/daughter during his/her period of training, as is deemed necessary by a qualified practitioner.

I understand that care at a military medical facility for non-military dependents will normally be rendered on a temporary (emergency) basis only; if further care is indicated, the patient will be transferred to non-military care as soon as possible.  Emergency care provided to cadets who are not military dependents at a military medical facility may be subject to reimbursement, and I may be billed for the care provided.  For Navy and Marine Corps sponsored activities, such care is authorized by NAVMEDCOMINST 6320.3B.

My son/daughter/ward has been determined to have the following allergies:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

He/she requires medication for the treatment of:

______________________________________________________________________

______________________________________________________________________

Below are listed any other medical conditions which my son/daughter/ward is known to have, which would preclude or limit in any way his/her participation in physical exercise and athletic programs.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

CNET-GEN 5800/4 (Rev. 1-95)

His/Her physician is:

Name: _____________________________________

Address: ____________________________________

Telephone: (include area code) ___________________

Medical/Injury Co. Insurance Info*                    Dental Insurance Info*:

_________________________                      _______________________________

(name)                                                              (name)

__________________________                    _______________________________

(street)                                                             (street)

___________________________                  _________________________________

(city, state, zip code)                                         (city, state, zip code)

____________________________                _________________________________

(Policy/ID Number)                                          (Policy/ID Number)

____________________________                __________________________________

(Telephone Confirmation #)                              (Telephone Confirmation #)

*This insurance is not required. However, the information provided may be required to obtain non-emergency care.

PRIVACY ACT NOTIFICATION

Under the authority of 5 U.S.C. Sec. 301, the information regarding your child’s/ward’s health, medical condition and treatment is requested, in order to verify any need to administer medication and to enable medical/dental personnel to diagnose and treat any emergency condition which may arise during training.  Pursuant to the Privacy Act, 5 U.S.C. Sec 552, the requested information will not be divulged without your written authorization to anyone other than NJROTC area personnel involved with administration of NJROTC activities, and medical/dental personnel requiring the information in order to effectively treat any health problem which may arise.  Disclosure is voluntary; however, failure to provide the requested information will preclude your child’s/ward’s participation in the training.

_________________________________________________

(signature of parent/guardian)

_________________________________________________

(address)

_________________________________________________

(city)                (state)                                       (zip)

__________________________________________________

(telephone:  home)                                            (work)