APPLICATION FOR CAP ENCAMPMENT OR SPECIAL ACTIVITY
FILL IN THE FOLLOWING PAGES AS ACCURATELY AND COMPLETELY AS POSSIBLE. PLEASE TYPE OR PRINT NEATLY. IF FORMS ARE NOT LEGIBLE THEN YOU MAY NOT BE SELECTED FOR THE ENCAMPMENT OR SPECIAL ACTIVITY THAT YOU WANT TO ATTEND
NAME (Last Name, First Name, Middle Initial)

JOINED CAP: MM YY

CAPSN

CAP GRADE

UNIT CHARTER NUMBER

117	REGION

WING

NY
MAILING ADDRESS (Number and Street)

.
(City)

(State)

(Zip Code)

DATE OF BIRTH: MM DD YY

HEIGHT

WEIGHT

GENDER

HAIR COLOR

EYE COLOR

TELEPHONE

(Home):

SCHOLASTIC ACHIEVEMENT

High School Graduate

RELIGIOUS PREFERENCE

(Alternate):

College	0 Years

Post Graduate	0 Years	PRESENT OCCUPATION

(Business):

E-MAIL ADDRESS

(Fax):

DO YOU WISH TO ATTEND MORE THAN ONE SPECIAL ACTIVITY OR ENCAMPMENT?	YES	NO
SPECIAL ACTIVITY OR ENCAMPMENT	LOCATION	SLOT DESIRED (If other than Basic/General Participant)	RANK ORDER

AIR EDUCATION AND TRAINING COMMAND FAMILIARIZATION COURSE
AIR FORCE SPACE COMMAND FAMILIARIZATION COURSE	Escort (FL Only)
CADET OFFICER SCHOOL	Cadet Staff	Seminar Advisor
HAWK MOUNTAIN RANGER SCHOOL
NATIONAL BLUE BERET	Cadet Staff	Senior Staff
NATIONAL FLIGHT ENCAMPMENT	Administrative	Instructor	Maintenance
NATIONAL GLIDER ENCAMPMENT	Administrative	Instructor	Maintenance
NATIONAL GROUND SEARCH AND RESCUE SCHOOL	Advanced	Cadet Staff	Senior Staff
PARARESCUE ORIENTATION COURSE
ADVANCED PARARESCUE ORIENTATION COURSE	Mountaineering	Navigation
OTHER SPECIAL ACTIVITY OR ENCAMPMENT (National, Region, or Wing)

CAP FORM 31 NOV 96	PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE.	CONTINUE ON TO BACK

TO BE COMPLETED BY FLIGHT AND GROUND INSTRUCTOR APPLICANTS
FAA CERTIFICATES AND RATINGS

CFI CERTIFICATE NUMBER & EXPIRATION DATE

MEDICAL CERTIFICATE CLASS & DATE

TOTAL FLIGHT TIME IN HOURS

TOTAL FLIGHT TIME IN HOURS (Last 12 Months)

AIRCRAFT FLOWN (Last 12 Months)

TOTAL FLIGHT INSTRUCTION GIVEN IN HOURS

FLIGHT INSTRUCTION GIVEN IN HOURS (Last 12 Months)

AIRCRAFT FLOWN IN INSTRUCTION (Last 12 Months)

TOTAL SOLO ENDORSEMENTS

TOTAL SOLO ENDORSEMENTS (Last 12 Months)

AIRCRAFT FLOWN IN SOLOS ENDORSED (Last 12 Months)

CAP FORM 5 CHECKRIDE DATE

AIRCRAFT MAKES AND MODEL AUTHORIZED ON CAPF5

PLEASE INCLUDE A COPY OF YOUR PILOT LOGBOOK FOR THE LAST 12 MONTHS AND A COPY OF YOUR CURRENT CAPF 5 WITH THIS APPLICATION.
TO BE COMPLETED BY MAINTENANCE OFFICER APPLICANTS
FAA CERTIFICATES AND RATINGS

CERTIFICATE NUMBER & EXPIRATION DATE

TO BE COMPLETED BY INTERNATIONAL AIR CADET EXCHANGE APPLICANTS
FOREIGN LANGUAGE EXPERIENCE

LANGUAGE	SPEAKING ABILITY	WRITING ABILITY	OVERALL UNDERSTANDING
Good	Fair	Poor	Good	Fair	Poor	Good	Fair	Poor
Good	Fair	Poor	Good	Fair	Poor	Good	Fair	Poor
COUNTRY PREFERENCE (Countries are announced each year in the November issue of the Civil Air Patrol News.)
1.

2.

3.

AIRPORT INFORMATION (List the Name, City, and State of the two closest major airports within 250 miles of your home. This information will be used to purchase your airline ticket once selected.)
1.

2.

RELEVANT EXPERIENCE (Use this section to relate any CAP or non-CAP experiences that could have a beneficial impact on your being selected to attend the special activity or encampment that
you have requested. Use an additional sheet if necessary, but please limit additional documentation.)

CAP FORM 31 NOV 96 PAGE 2/4	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.
HAVE YOU EVER HAD AN FAA OR OTHER FLIGHT PHYSICAL DENIED, SUSPENDED, OR REVOKED?	NO	YES (Give the date and reason in the remarks section.)
DO YOU CURRENTLY USE ANY MEDICATION? (Including eye drops)	NO	YES (List any medication taken and the reason in the remarks section.)
HAVE YOU HAD OR BEEN INVOLVED IN AN ACCIDENT IN THE PAST 2 YEARS?	NO	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.)

NO	YES	Frequent or severe headaches	NO	YES	Ear infections	NO	YES	Chronic diseases like Diabetes or Bronchitis

NO	YES	Dizziness or fainting spells	NO	YES	Rupture	NO	YES	Girls only - Menstrual cramps

NO	YES	Unconsciousness for any reason	NO	YES	Positive TB skin test	NO	YES	Other illness or accidents

NO	YES	Eye trouble, excluding glasses	NO	YES	Epilepsy or fits	NO	YES	Military rejection or medical discharge

NO	YES	Hay fever	NO	YES	Kidney stones or blood in urine	NO	YES	Rejection for life insurance

NO	YES	Sugar or albumin in urine	NO	YES	Motion sickness	NO	YES	Admission to hospital

NO	YES	Heart trouble	NO	YES	Nervous trouble of any sort	NO	YES	Record of traffic convictions

NO	YES	High or low blood pressure	NO	YES	Any known allergies	NO	YES	Record of other convictions

NO	YES	Stomach trouble	NO	YES	Any drug or narcotic habit	NO	YES	Attempted suicide

NO	YES	Asthma	NO	YES	Chronic or recurring injuries	NO	YES	Medical treatment within the past 5 years other than regular office visits or physicals
IMMUNIZATIONS

FAMILIY PHYSICIAN (Name, address, and phone number)

INSURANCE INFORMATION

Medical	Liability

Company	Company

Policy Number	Policy Number

EMERGENCY ADDRESSEE - PARENT, GUARDIAN, OR CLOSEST RELATIVE TO BE NOTIFIED IN CASE OF EMERGENCY

Name	Relationship

Address	Day Telephone	Night Telephone

REMARKS

CAP FORM 31 NOV 96 PAGE 3/4	CONTINUE ON TO LAST PAGE

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.

DATE	SIGNATURE OF APPLICANT
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.

DATE	WITNESS FOR FATHER’S SIGNATURE	FATHER OR LEGAL GUARDIAN

WITNESS FOR MOTHER’S SIGNATURE	MOTHER OR LEGAL GUARDIAN
SQUADRON CERTIFICATION

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. This applicant is the

choice of	cadets/seniors in this squadron applying for	.

SQUADRON COMMANDER
WING CERTIFICATION (Mandatory for all but Region Staff Applicants)

This applicant is the	choice of	cadets/seniors in this Wing applying for	.

WING COMMANDER / BOARD PRESIDENT
REGION CERTIFICATION (IACE Escorts and Region Staff Applicants Only)

This applicant is the	choice of	cadets/seniors in this Region applying for	.

REGION COMMANDER
APPLICATION CHECKLIST

APPLICATION IS FILLED OUT COMPLETELY AND LEGIBLY, AND HAS ALL SUPPORTING DOCUMENTATION ATTACHED

APPROPRIATE NUMBER OF COPIES OF APPLICATION HAVE BEEN MADE (3 FOR NATIONAL CADET SPECIAL ACTIVITES)

REQUIRED SIGNATURES HAVE BEEN OBTAINED

CHECK(S) OR MONEY ORDER(S) IS(ARE) ATTACHED IF REQUIRED (CHECKS ARE MAILED SEPARATELY FOR NATIONAL CADET SPECIAL ACTIVITIES)

COPIES HAVE BEEN FORWARDED OR RETAINED AS REQUIRED (FOR NATIONAL CADET SPECIAL ACTIVITIES MEMBERS RETAIN ONE COPY, FORWARD ONE TO THEIR WING REVIEW BOARD, AND FORWARD THE THIRD COPY TO NATIONAL HEADQUARTERS BY 31 JANUARY AT THE FOLLOWING ADDRESS:

HQ CAP/CP

105 SOUTH HANSELL STREET

MAXWELL AFB AL 36112-6332
CAP FORM 31 NOV 96 PAGE 4/4

Application for CAP Encampment or Special Activity

D. Charles Kowalewski, DO

2003-07-16

PRIMARY