Cap Form 31 – Fill Out and Use This PDF

APPLICATION FOR CAP ENCAMPMENT OR SPECIAL ACTIVITY

RELEASE AGREEMENT

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.

RELEASE BY PARENTS OR GUARDIAN

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.

Squadron Certification. (Squadron Commander’s signature is not necessary if the activity is approved in eServices or if it is a squadron activity.)

I certify that the above information is correct and that all requirements for attendance, as specified in National Headquarters Directives, will be completed by the required dates.

Group Certification. (Group Commander’s signature is not necessary if the activity is approved in eServices or if the activity is held within the group.)

Wing Certification. (Wing Commander’s signature is not necessary if the activity is approved in eServices or if the activity is held within the wing.)

CAP MEMBER HEALTH HISTORY FORM

This information is CONFIDENTIAL and for official use only. It cannot be released to unauthorized persons. Answer all questions as accurately as possible so that the activity or encampment staff can make themselves aware of any pre-existing medical problems or conditions and be alert to help you. This form will also provide medical information in a case when you are unable to do so.

Allergies: List Names of Medication or Other Allergies (i.e., bee sting, food, plants) and types of reactions; please note food allergy details with dietary restrictions below on back as well.

Do You Now Have Or Have You Ever Had Any Of The Following? Explain any yes’ in the remarks section below or attach additional sheet. Conditions not specifically noted below having the potential to interfere with performance during the special activity or encampment should be documented in the remarks section.)

If “Yes” is marked in an item with multiple choices, please circle which problem applies.

EMERGENCY INFORMATION

(Insurance/Physician Information, Emergency Contacts, Minor Consents

Primary Insurance Information (Please attach copy of insurance cards, front and back)

Family Physician

Emergency Contact (Parent, guardian or closest relative to be notified in case of emergency)

Dietary Restrictions or Limitations (List any dietary restrictions like food allergies, diabetes, gluten-free, vegetarian diets, etc.)

Past Surgical History (List all surgeries including tonsils, ear tubes, appendix, gall bladder, hernia, hysterectomy, heart, heart catheterization, bone and joint and all other surgeries.)

Medication Information - Include supplements, over-the-counter medicines, herbals, creams, etc., or write “None”.

Social History

Remarks (Attach additional sheet if needed)

CONSENT FOR MINOR CADET PARTICIPATION, MEDICATIONS, TREATMENT

I give permission for full participation in CAP programs, subject to any limitations noted herein.

My signature below evidences my consent for my child/ward to possess and self-administer the prescription medications listed above I understand that there are legal limitations imposed on CAP senior members with regard to the involuntary administration of medications to my child/ward. (Cross out if permission is denied).

In case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge exam/test results and treatment provided.

CAP Form 160 Reverse

PERMISSION FOR PROVISION OF MINOR CADET OVER-THE-COUNTER MEDICATION

This form may not be usable in some states due to statutes concerning who can administer medications and administration conditions. Wings with such restrictions will publish appropriate additional guidance in a supplement to CAPR 160-1.

Over-The Counter/Non-Prescription Medications

The following over-the counter medications may be administered according to package directions by CAP senior members. Cross out any medications not approved.

Allergies

My child/ward has the following allergies or reactions to over-the-counter medications (list type of reaction):

Consent For Minor Cadet To Receive Over-The-Counter Medications My signature below evidences my consent for CAP senior members to provide over-the- counter non-prescription medications (such as those listed above) to my child/ward if indicated in the reasonable judgment of such senior members. I understand that I will be informed if any such medications are administered.