<table style="width:100%;">
<colgroup>
<col style="width: 12%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 30%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="13"><strong>APPLICATION FOR CAP ENCAMPMENT OR SPECIAL
ACTIVITY</strong></td>
</tr>
<tr class="even">
<td colspan="13"><em>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.</em></td>
</tr>
<tr class="odd">
<td colspan="9"><p>NAME (Last Name, First Name, Middle Initial)</p>
<p>     </p></td>
<td colspan="3"><p>JOINED CAP: MM YY</p>
<p>     </p></td>
<td rowspan="4"><img src="media/image1.jpeg"
style="width:2in;height:2in" /></td>
</tr>
<tr class="even">
<td colspan="2"><p>CAPSN</p>
<p>     </p></td>
<td colspan="3"><p>CAP GRADE</p>
<p>     </p></td>
<td colspan="4"><p>UNIT CHARTER NUMBER</p>
<p>     </p></td>
<td colspan="2"><p>REGION</p>
<p>     </p></td>
<td><p>WING</p>
<p>   </p></td>
</tr>
<tr class="odd">
<td colspan="12"><p>MAILING ADDRESS (Number and Street)</p>
<p>     </p>
<p><em>.</em></p></td>
</tr>
<tr class="even">
<td colspan="6"><p>(City)</p>
<p>     </p></td>
<td colspan="2"><p>(State)</p>
<p>   </p></td>
<td colspan="4"><p>(Zip Code)</p>
<p>          </p></td>
</tr>
<tr class="odd">
<td><p>DATE OF BIRTH: MM DD YY</p>
<p>     </p></td>
<td colspan="2"><p>HEIGHT (inches)</p>
<p>  </p></td>
<td><p>WEIGHT (lbs)</p>
<p>   </p></td>
<td colspan="3"><p>GENDER</p></td>
<td colspan="3"><p>HAIR COLOR</p>
<p>     </p></td>
<td colspan="2"><p>EYE COLOR</p>
<p>     </p></td>
<td><p>TELEPHONE</p>
<p>(Home):</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>SCHOLASTIC ACHIEVEMENT</p>
<p> High School Graduate</p></td>
<td colspan="9"><p>RELIGIOUS PREFERENCE</p>
<p>     </p></td>
<td><p>(Alternate):</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3"><p> College    Years</p>
<p> Post Graduate    Years</p></td>
<td colspan="9"><p>PRESENT OCCUPATION</p>
<p>     </p></td>
<td><p>(Business):</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="12"><p>E-MAIL ADDRESS</p>
<p>     </p></td>
<td><p>(Fax):</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="13">DO YOU WISH TO ATTEND MORE THAN ONE SPECIAL ACTIVITY OR
ENCAMPMENT? YES NO</td>
</tr>
<tr class="even">
<td colspan="13"><p>SPECIAL ACTIVITY OR ENCAMPMENT LOCATION SLOT DESIRED
(If other than Basic/General Participant) RANK ORDER</p>
<p> AIR EDUCATION AND TRAINING COMMAND FAMILIARIZATION COURSE   
  </p></td>
</tr>
<tr class="odd">
<td colspan="13"> AIR FORCE SPACE COMMAND FAMILIARIZATION COURSE   
Escort (FL Only)   </td>
</tr>
<tr class="even">
<td colspan="13"> CADET OFFICER SCHOOL Cadet Staff Seminar Advisor
  </td>
</tr>
<tr class="odd">
<td colspan="13"> HAWK MOUNTAIN RANGER SCHOOL         </td>
</tr>
<tr class="even">
<td colspan="13"> NATIONAL BLUE BERET Cadet Staff Senior Staff   </td>
</tr>
<tr class="odd">
<td colspan="13"> NATIONAL FLIGHT ENCAMPMENT    Administrative
Instructor Maintenance   </td>
</tr>
<tr class="even">
<td colspan="13"> NATIONAL GLIDER ENCAMPMENT    Administrative
Instructor Maintenance   </td>
</tr>
<tr class="odd">
<td colspan="13"> NATIONAL GROUND SEARCH AND RESCUE SCHOOL Advanced
Cadet Staff Senior Staff   </td>
</tr>
<tr class="even">
<td colspan="13"> PARARESCUE ORIENTATION COURSE      </td>
</tr>
<tr class="odd">
<td colspan="13"> ADVANCED PARARESCUE ORIENTATION COURSE Mountaineering
Navigation   </td>
</tr>
<tr class="even">
<td colspan="13"><p>OTHER SPECIAL ACTIVITY OR ENCAMPMENT (National,
Region, or Wing)</p>
<p>                  </p>
<p>                  </p>
<p>                  </p></td>
</tr>
</tbody>
</table>

CAP FORM 31 JUN 07 PREVIOUS EDITIONS MAY BE USED. CONTINUE ON TO BACK

<table>
<colgroup>
<col style="width: 14%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 24%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><strong>TO BE COMPLETED BY FLIGHT AND GROUND INSTRUCTOR
APPLICANTS</strong></td>
</tr>
<tr class="even">
<td colspan="5"><p>FAA CERTIFICATES AND RATINGS</p>
<p>     </p></td>
<td colspan="7"><p>CFI CERTIFICATE NUMBER &amp; EXPIRATION DATE</p>
<p>           </p></td>
<td colspan="2"><p>MEDICAL CERTIFICATE CLASS &amp; DATE</p>
<p>           </p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>TOTAL FLIGHT TIME IN HOURS</p>
<p>     </p></td>
<td colspan="6"><p>TOTAL FLIGHT TIME IN HOURS (Last 12 Months)</p>
<p>     </p></td>
<td colspan="6"><p>AIRCRAFT FLOWN (Last 12 Months)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2"><p>TOTAL FLIGHT INSTRUCTION GIVEN IN HOURS</p>
<p>     </p></td>
<td colspan="6"><p>FLIGHT INSTRUCTION GIVEN IN HOURS (Last 12
Months)</p>
<p>     </p></td>
<td colspan="6"><p>AIRCRAFT FLOWN IN INSTRUCTION (Last 12 Months)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>TOTAL SOLO ENDORSEMENTS</p>
<p>     </p></td>
<td colspan="6"><p>TOTAL SOLO ENDORSEMENTS (Last 12 Months)</p>
<p>     </p></td>
<td colspan="6"><p>AIRCRAFT FLOWN IN SOLOS ENDORSED (Last 12 Months)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td><p>CAP FORM 5 CHECKRIDE DATE</p>
<p>     </p></td>
<td colspan="9"><p>AIRCRAFT MAKES AND MODEL AUTHORIZED ON CAPF5</p>
<p>     </p></td>
<td colspan="4"><strong>PLEASE INCLUDE A COPY OF YOUR PILOT LOGBOOK FOR
THE LAST 12 MONTHS AND A COPY OF YOUR CURRENT CAPF 5 WITH THIS
APPLICATION.</strong></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>TO BE COMPLETED BY MAINTENANCE OFFICER
APPLICANTS</strong></td>
</tr>
<tr class="even">
<td colspan="9"><p>FAA CERTIFICATES AND RATINGS</p>
<p>     </p></td>
<td colspan="5"><p>CERTIFICATE NUMBER &amp; EXPIRATION DATE</p>
<p>           </p></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>TO BE COMPLETED BY INTERNATIONAL AIR CADET
EXCHANGE APPLICANTS</strong></td>
</tr>
<tr class="even">
<td colspan="3"><p>FOREIGN LANGUAGE EXPERIENCE</p>
<p>LANGUAGE</p></td>
<td colspan="4">SPEAKING ABILITY</td>
<td colspan="6">WRITING ABILITY</td>
<td>OVERALL UNDERSTANDING</td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td colspan="4"> Good Fair Poor</td>
<td colspan="6"> Good Fair Poor</td>
<td> Good Fair Poor</td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td colspan="4"> Good Fair Poor</td>
<td colspan="6"> Good Fair Poor</td>
<td> Good Fair Poor</td>
</tr>
<tr class="odd">
<td colspan="14">COUNTRY PREFERENCE (Countries are announced each year
in the November issue of the <em>Civil Air Patrol News.</em>)</td>
</tr>
<tr class="even">
<td colspan="4"><p>1.</p>
<p>     </p></td>
<td colspan="7"><p>2.</p>
<p>     </p></td>
<td colspan="3"><p>3.</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="14">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.)</td>
</tr>
<tr class="even">
<td colspan="6"><p>1.      </p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8"><p>2.      </p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="14"><p>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<br />
you have requested. Use an additional sheet if necessary, but please
limit additional documentation.)</p>
<p>     </p></td>
</tr>
</tbody>
</table>

**CAP FORM 31 JUN 07 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 JUN 07 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 [.]{.underline}                                                   |
|                                                                       |
| > 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 [.]{.underline}                                          |
|                                                                       |
| > REGION COMMANDER                                                    |
+-----------------------------------------------------------------------+
| **APPLICATION CHECKLIST**                                             |
|                                                                       |
| **APPLICATION IS FILLED OUT COMPLETELY AND LEGIBLY, AND HAS ALL       |
| SUPPORTING DOCUMENTATION ATTACHED**                                   |
|                                                                       |
| **REQUIRED SIGNATURES HAVE BEEN OBTAINED**                            |
|                                                                       |
| **CHECK(S) OR MONEY ORDER(S) IS(ARE) ATTACHED IF REQUIRED**           |
|                                                                       |
| **KEEP A COPY OF THIS COMPLETED FORM FOR YOUR OWN RECORDS.**          |
|                                                                       |
| **SEND THIS COMPLETED FORM TO THE APPROPRIATE OFFICE:\                |
| \                                                                     |
| FOR NATIONAL CADET SPECIAL ACTIVITIES:** Please follow the            |
| instructions found at www.cap.gov/ncsa.                               |
|                                                                       |
| **FOR OTHER CADET ACTIVITIES, SUCH AS SUMMER ENCAMPMENTS**: Follow    |
| the instructions provided by the Activity Director, or see your       |
| Squadron Commander.                                                   |
+-----------------------------------------------------------------------+

CAP FORM 31 JUN 07 PAGE 4/4