ࡱ> PSMNO[@ bjbj44 6ViVi= bbbb&" .B```8`T6bB؞,c pppp)rt }AT+------$RVQA8>%r)rP \Qbbpp;d"b8pp+>+dpc ;i`v0؞՗$$4BBbbbb$ 7Æ{QQBB#;$"BB;APPLICATION FOR CAP ENCAMPMENT OR SPECIAL ACTIVITYFILL 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 HANDRITTEN / TYPED USE IS PROHIBITED.NAME (Last Name, First Name, Middle Initial)  FORMTEXT      JOINED CAP: MM YY  FORMTEXT       INCLUDEPICTURE "http://mswg.cap.gov/../../../../My%20Documents/capf031.jpg" \* MERGEFORMATINET \d CAPSN  FORMTEXT      CAP GRADE  FORMDROPDOWN UNIT CHARTER NUMBER  FORMTEXT 117REGION  FORMDROPDOWN WING  FORMTEXT NYMAILING ADDRESS (Number and Street)  FORMTEXT       .(City)  FORMTEXT      (State)  FORMTEXT    (Zip Code)  FORMTEXT        FORMTEXT     DATE OF BIRTH: MM DD YY  FORMTEXT      HEIGHT  FORMTEXT   WEIGHT  FORMTEXT      GENDER  FORMDROPDOWN HAIR COLOR  FORMTEXT      EYE COLOR  FORMTEXT      TELEPHONE (Home):  FORMTEXT      SCHOLASTIC ACHIEVEMENT  FORMCHECKBOX  High School Graduate RELIGIOUS PREFERENCE  FORMTEXT      (Alternate):  FORMTEXT       FORMCHECKBOX  College  FORMTEXT 0 Years  FORMCHECKBOX  Post Graduate  FORMTEXT 0 YearsPRESENT OCCUPATION  FORMTEXT      (Business):  FORMTEXT      E-MAIL ADDRESS  FORMTEXT      (Fax):  FORMTEXT      DO YOU WISH TO ATTEND MORE THAN ONE SPECIAL ACTIVITY OR ENCAMPMENT?  FORMCHECKBOX  YES  FORMCHECKBOX  NOSPECIAL ACTIVITY OR ENCAMPMENT LOCATION SLOT DESIRED (If other than Basic/General Participant) RANK ORDER  FORMCHECKBOX  AIR EDUCATION AND TRAINING COMMAND FAMILIARIZATION COURSE  FORMTEXT     FORMTEXT    FORMCHECKBOX  AIR FORCE SPACE COMMAND FAMILIARIZATION COURSE  FORMTEXT     FORMCHECKBOX  Escort (FL Only)  FORMTEXT    FORMCHECKBOX  CADET OFFICER SCHOOL  FORMCHECKBOX  Cadet Staff  FORMCHECKBOX  Seminar Advisor  FORMTEXT    FORMCHECKBOX  HAWK MOUNTAIN RANGER SCHOOL  FORMCHECKBOX   FORMTEXT        FORMTEXT    FORMCHECKBOX  NATIONAL BLUE BERET  FORMCHECKBOX  Cadet Staff  FORMCHECKBOX  Senior Staff  FORMTEXT    FORMCHECKBOX  NATIONAL FLIGHT ENCAMPMENT  FORMTEXT     FORMCHECKBOX  Administrative  FORMCHECKBOX  Instructor  FORMCHECKBOX  Maintenance  FORMTEXT    FORMCHECKBOX  NATIONAL GLIDER ENCAMPMENT  FORMTEXT     FORMCHECKBOX  Administrative  FORMCHECKBOX  Instructor  FORMCHECKBOX  Maintenance  FORMTEXT    FORMCHECKBOX  NATIONAL GROUND SEARCH AND RESCUE SCHOOL  FORMCHECKBOX  Advanced  FORMCHECKBOX  Cadet Staff  FORMCHECKBOX  Senior Staff  FORMTEXT    FORMCHECKBOX  PARARESCUE ORIENTATION COURSE  FORMTEXT     FORMTEXT    FORMCHECKBOX  ADVANCED PARARESCUE ORIENTATION COURSE  FORMCHECKBOX  Mountaineering  FORMCHECKBOX  Navigation  FORMTEXT   OTHER SPECIAL ACTIVITY OR ENCAMPMENT (National, Region, or Wing)  FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT     FORMCHECKBOX   FORMTEXT        FORMTEXT   CAP FORM 31 NOV 96 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE. CONTINUE ON TO BACK TO BE COMPLETED BY FLIGHT AND GROUND INSTRUCTOR APPLICANTSFAA CERTIFICATES AND RATINGS  FORMTEXT      CFI CERTIFICATE NUMBER & EXPIRATION DATE  FORMTEXT        FORMTEXT      MEDICAL CERTIFICATE CLASS & DATE  FORMTEXT        FORMTEXT      TOTAL FLIGHT TIME IN HOURS  FORMTEXT      TOTAL FLIGHT TIME IN HOURS (Last 12 Months)  FORMTEXT      AIRCRAFT FLOWN (Last 12 Months)  FORMTEXT      TOTAL FLIGHT INSTRUCTION GIVEN IN HOURS  FORMTEXT      FLIGHT INSTRUCTION GIVEN IN HOURS (Last 12 Months)  FORMTEXT      AIRCRAFT FLOWN IN INSTRUCTION (Last 12 Months)  FORMTEXT      TOTAL SOLO ENDORSEMENTS  FORMTEXT      TOTAL SOLO ENDORSEMENTS (Last 12 Months)  FORMTEXT      AIRCRAFT FLOWN IN SOLOS ENDORSED (Last 12 Months)  FORMTEXT      CAP FORM 5 CHECKRIDE DATE  FORMTEXT      AIRCRAFT MAKES AND MODEL AUTHORIZED ON CAPF5  FORMTEXT       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 APPLICANTSFAA CERTIFICATES AND RATINGS  FORMTEXT      CERTIFICATE NUMBER & EXPIRATION DATE  FORMTEXT        FORMTEXT      TO BE COMPLETED BY INTERNATIONAL AIR CADET EXCHANGE APPLICANTSFOREIGN LANGUAGE EXPERIENCE LANGUAGESPEAKING ABILITYWRITING ABILITYOVERALL UNDERSTANDING FORMTEXT       FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMTEXT       FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  Poor FORMCHECKBOX  Good  FORMCHECKBOX  Fair  FORMCHECKBOX  PoorCOUNTRY PREFERENCE (Countries are announced each year in the November issue of the Civil Air Patrol News.)1.  FORMTEXT      2.  FORMTEXT      3.  FORMTEXT      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.  FORMTEXT        FORMTEXT      2.  FORMTEXT        FORMTEXT      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.)  FORMTEXT      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?  FORMCHECKBOX  NO  FORMCHECKBOX  YES (Give the date and reason in the remarks section.)DO YOU CURRENTLY USE ANY MEDICATION? (Including eye drops)  FORMCHECKBOX  NO  FORMCHECKBOX  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?  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  FORMCHECKBOX  Liability Company Company  FORMTEXT        FORMTEXT       Policy Number Policy Number  FORMTEXT        FORMTEXT      EMERGENCY ADDRESSEE - PARENT, GUARDIAN, OR 235 2 4 a b l m 2 4 H J L V X Z \ ^ " $ & ( 8 : N ´´tffXf´j@hNCJ OJQJUjhNCJ OJQJU!jhNCJOJQJU&jhNCJOJQJUmHnHu!j2hNCJOJQJUhNCJOJQJjhNCJOJQJUhNCJ OJQJ$hN56<B*CJOJQJphhN6CJ OJQJjhN0J<UhN5OJQJ453 4 (_kd$$IfTl    r'' 0    4 laT <$If]_kd$$IfTl    r''0    4 laT $<$Ifa$*D4 a  2 \ * , 8 ` t GV0GV0b!GV!$GV$kd]$$IfTl4    F7?r'`3 0        4 laf4T Y<$If<$If N P R \ ^ t v    " 6 8 : > @ วถsb!jhNCJOJQJU'jhNhNCJOJQJUhNCJOJQJmHnHu!jhNCJOJQJU!jhNCJOJQJUhNCJOJQJhNCJ OJQJ&jhNCJOJQJUmHnHujhNCJOJQJU!j^hNCJOJQJU  B D GVGVGV<$If<$If]^`D F =5GV/$GV $<$Ifa$$If<$Ifkd<$$IfTl4    ֈ 7?r' 3 0    4 laf4T      $ & > @ T V X b d f h | ~ ·’p_!j, hNCJOJQJU!j hNCJOJQJU!jH hNCJOJQJU!j hNCJOJQJUhNCJOJQJhNCJ OJQJhN6CJ OJQJhNCJOJQJ&jhNCJOJQJUmHnHujhNCJOJQJU!jc hNCJOJQJU%  ( > w GVw TGVTX GVuX  ;<$Ifukd $$IfTl4    00?r' 3 0    4 laf4T<$If &Nc[GV[[PGVP[GVP $<$Ifa$<$Ifkd $$IfTl4    \ ?r'O,0 3  0    4 laf4T &(<>@JL\^z|~ޯԞޯԍޯ|kޯ!jWhNCJOJQJU!jhNCJOJQJU!j%hNCJOJQJU!jhNCJOJQJU&jhNCJOJQJUmHnHu!j hNCJOJQJUhNCJOJQJjhNCJOJQJUhNCJ OJQJhNCJOJQJ%N\FGV'GV'wGVw[ GV[ GV[ <$If$<$If]^a$<$If]^  468BD\^tvx 024HJLVX\วฌ¸{j!jhNCJOJQJU!jhNCJOJQJU!jhNCJOJQJUhNCJOJQJ!jhNCJOJQJUhNCJOJQJhNCJ OJQJ&jhNCJOJQJUmHnHujhNCJOJQJU!jhNCJOJQJU)FHv/'x$If<$Ifkd[$$IfTl    ֞e ?r'(}O2 0    4 laT2Z\*Pg[1Q1GV F$If F($Ifkd$$IfTl    F?r' 3 0        4 laT<$If $If \^z|~(*PRfhj̀o!jhNCJOJQJUhNCJOJQJ!jhNCJOJQJU!jChNCJOJQJUhNCJOJQJmHnHu!jhNCJOJQJUhNCJ OJQJ!jhNCJOJQJUhNCJOJQJjhNCJOJQJU$jtvxz$&(248 ԁyjyԁyjhNOJQJUhNOJQJjhNOJQJU!jhNCJOJQJU!jhNCJOJQJU!jhNCJOJQJUhNCJOJQJhNCJOJQJhNCJ OJQJjhNCJOJQJU&jhNCJOJQJUmHnHu&Px6[ R[ qGV[ kd-$$IfTl    F?r' 3 0        4 laT<$If68~_kd$$IfTl    r'' 0    4 laT <$Ifrkd$$IfTl    0?r'3 0    4 laT RThjĺĺĄĺĺsĄĺbĺQ!jQ hNCJOJQJU!jhNCJOJQJU!jhNCJOJQJU&jhNCJOJQJUmHnHu!jhNCJOJQJU!jWhNCJOJQJUhNCJOJQJjhNCJOJQJUhNCJ OJQJhNOJQJjhNOJQJUj?hNOJQJU'GVw']kdS$$IfTl    r''0    4 laT hu? 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