<table>
<colgroup>
<col style="width: 14%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="19"><strong>CALIFORNIA WING – APPLICATION FOR CAP
ACTIVITY</strong></td>
</tr>
<tr class="even">
<td colspan="2"><p>CAP ID NUMBER (6 DIGITS)</p>
<p>     </p></td>
<td colspan="2"><p>REGION</p>
<p>     </p></td>
<td colspan="4"><p>WING</p>
<p>  </p></td>
<td colspan="2"><p>Group</p>
<p>    </p></td>
<td colspan="4"><p>Squadron</p>
<p>    </p></td>
<td colspan="2"><p>CHARTER #</p>
<p>CA-???</p></td>
<td colspan="2"><p> CADET</p>
<p> SENIOR</p></td>
<td><p> MALE</p>
<p> FEMALE</p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>NAME (LAST, FIRST MIDDLE INITIAL)</p>
<p>     </p></td>
<td colspan="4"><p>cap gRADE</p>
<p>     </p>
<p> </p></td>
<td colspan="2"><p>DATE JOINED CAP MMM-yyyy</p>
<p>     </p></td>
<td colspan="3"><p>Home Telephone (With area code)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="16"><p>MAILING ADDRESS (Number &amp; Street) Apartment or
Space Number</p>
<p>     </p></td>
<td colspan="3"><p>BUSINESS TELEPHONE (WITH AREA CODE)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="9"><p>CITY</p>
<p>     </p></td>
<td colspan="3"><p>STATE</p>
<p>  </p></td>
<td colspan="4"><p>ZIP CODE</p>
<p>     </p></td>
<td colspan="3"><p>CELL PHONE NUMBER (With area code)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td><p>DATE OF BIRTH</p>
<p>(dd MMM yy)</p>
<p>     </p></td>
<td colspan="2"><p>HEIGHT</p>
<p>  </p></td>
<td colspan="2"><p>WEIGHT</p>
<p>   </p></td>
<td colspan="4"><p>SCHOOL GRADE</p>
<p>(CADETS ONLY)</p>
<p>     </p></td>
<td colspan="10"><p>EMAIL ADDRESS</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong>ACTIVITY REQUESTED (One activity per
application, please)</strong></p>
<p>     </p></td>
<td colspan="9"><p><strong>LOCATION</strong></p>
<p>     </p></td>
<td colspan="5"><p><strong>DATE (dd-MMM-yy)</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>RELIGIOUS PREFERENCE</p>
<p>     </p></td>
<td colspan="10"><p>ARE YOU INTERESTED IN ATTENDING RELIGIOUS SERVICES
IF AVAILABLE?</p>
<p>YES NO </p></td>
<td colspan="5"><p><strong>Cadet Protection Training (18 AND OLDER
ONLY)</strong></p>
<p>Completed </p>
<p>Will be completed by activity </p></td>
</tr>
<tr class="odd">
<td colspan="7"><p>TRANSPORTATION: <em><strong>arrive</strong></em> BY:
pRIVATE vEHICLE cap vAN </p>
<p>DRIVER’S NAME:     </p></td>
<td colspan="4">tRAIN bUS aIRPLANE </td>
<td colspan="8"><p>SCHEDULE/FLIGHT/ARRIVAL LOCATION</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="7"><p>TRANSPORTATION: <em><strong>return</strong></em> BY:
pRIVATE vEHICLE cap vAN </p>
<p>DRIVER’S NAME:  </p></td>
<td colspan="4">tRAIN bUS aIRPLANE </td>
<td colspan="8"><p>SCHEDULE/FLIGHT/DEPARTURE LOCATION</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="13"><p>I would like to attend this activity as a:</p>
<p> Student/Participant</p>
<p> Cadet Staff Member – position requested :      </p>
<p> Senior Staff Member – position requested:      </p></td>
<td colspan="6"><p>T-Shirt Size<br />
(some activities may provide T-shirts)</p>
<p>S M L XL 2XL </p></td>
</tr>
<tr class="even">
<td colspan="19">Special Meals Required <em>(Special meals may not be
able to be accommodated)</em> What kind?      </td>
</tr>
<tr class="odd">
<td colspan="19"><strong>SENIORS ONLY - PARTICIPATION:</strong>
Full-Time Part-Time Part-Time Dates:      </td>
</tr>
<tr class="even">
<td colspan="17"><p><strong>PAYMENT OF EVENT FEES:</strong></p>
<p>I have included payment of $       in the form of: Cash: Check: Money
Order: </p>
<p>Credit Card: (attach/enclose CAWGF14 or online receipt)</p></td>
<td colspan="2">CAWG Use Only</td>
</tr>
<tr class="odd">
<td colspan="19"><p>Comments:      </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="6"><p><strong>Emergency Contact During Activity – Parent,
Guardian, or closest relative to be contacted in case of
emergency</strong></p>
<p>     </p></td>
<td colspan="9"><p><strong>Daytime Phone – MUST be available during
activity</strong></p>
<p>     </p></td>
<td colspan="4"><p><strong>Evening Phone – MUST be available during
activity</strong></p>
<p>     </p></td>
</tr>
</tbody>
</table>

**CAWGF150 (Version 1.03 -- 08/08) Replaces CAWGF31 which is obsolete
mmp-ajg**

+--------------------------+------+-------+--------------+------------+
| NAME (LAST, FIRST MI)    |      | CAPID | ACTIVITY     | DATE OF    |
|                          | C    |       |              | ACTIVITY   |
|                          | ADET |       |              |            |
|                          |      |       |              |            |
|                          | sE   |       |              |            |
|                          | NIOR |       |              |            |
+--------------------------+------+-------+--------------+------------+
| **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 or 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 of 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 such    |      |       |              |            |
| > 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, 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      |      |       |              |            |
| > 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.               |      |       |              |            |
|                          |      |       |              |            |
|                          |      |       |              |            |
|                          |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_     |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_           |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_           |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
|                          |      |       |              |            |
| Social Security Number   |      |       |              |            |
| -- Only if requested     |      |       |              |            |
| DATE SIGNATURE OF        |      |       |              |            |
| APPLICANT                |      |       |              |            |
+--------------------------+------+-------+--------------+------------+
| **RELEASE BY PARENT 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 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 and is able to |      |       |              |            |
| participate without the  |      |       |              |            |
| physical/emotional       |      |       |              |            |
| support of others. Also, |      |       |              |            |
| he/she is capable of     |      |       |              |            |
| taking any prescribed    |      |       |              |            |
| medications without      |      |       |              |            |
| supervision.             |      |       |              |            |
|                          |      |       |              |            |
| 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 he/she does not       |      |       |              |            |
| follow the               |      |       |              |            |
| activity/encampment      |      |       |              |            |
| rules, regula­tions, and  |      |       |              |            |
| directives he/she may be |      |       |              |            |
| sent home at the         |      |       |              |            |
| discretion of the        |      |       |              |            |
| project officer,         |      |       |              |            |
| encampment commander or  |      |       |              |            |
| activity director at my  |      |       |              |            |
| expense.                 |      |       |              |            |
|                          |      |       |              |            |
| 4\. Should firearms      |      |       |              |            |
| training be offered as   |      |       |              |            |
| outlined in CAPR 52-16,  |      |       |              |            |
| permission is hereby     |      |       |              |            |
| given for the applicant  |      |       |              |            |
| to participate.          |      |       |              |            |
|                          |      |       |              |            |
| However, in case of      |      |       |              |            |
| injury, disease or other |      |       |              |            |
| illness, permission is   |      |       |              |            |
| hereby granted to treat  |      |       |              |            |
| the participant 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 FATHER OR LEGAL     |      |       |              |            |
| GUARDIAN WITNESS FOR     |      |       |              |            |
| FATHER'S SIGNATURE       |      |       |              |            |
|                          |      |       |              |            |
| **(Must be signed by     |      |       |              |            |
| adult other than         |      |       |              |            |
| parent/legal guardian)** |      |       |              |            |
|                          |      |       |              |            |
| \_\_\_\_\_\_\_\_         |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_   |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
|                          |      |       |              |            |
| DATE MOTHER OR LEGAL     |      |       |              |            |
| GUARDIAN WITNESS FOR     |      |       |              |            |
| MOTHER'S SIGNATURE       |      |       |              |            |
|                          |      |       |              |            |
| **(Must be signed by     |      |       |              |            |
| adult other than         |      |       |              |            |
| parent/legal guardian)** |      |       |              |            |
+--------------------------+------+-------+--------------+------------+
| **UNIT COMMANDER'S       |      |       |              |            |
| CERTIFICATION**          |      |       |              |            |
|                          |      |       |              |            |
| *To my knowledge:*       |      |       |              |            |
|                          |      |       |              |            |
| 1\. I certify that       |      |       |              |            |
| **ALL** of the           |      |       |              |            |
| information on this form |      |       |              |            |
| is complete and correct. |      |       |              |            |
|                          |      |       |              |            |
| 2\. This applicant meets |      |       |              |            |
| the activity             |      |       |              |            |
| prerequisites and is     |      |       |              |            |
| prepared to attend this  |      |       |              |            |
| activity.                |      |       |              |            |
|                          |      |       |              |            |
| 3\. This applicant 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.               |      |       |              |            |
|                          |      |       |              |            |
| 4\. This applicant 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  |      |       |              |            |
| he/she does not follow   |      |       |              |            |
| the activity/encampment  |      |       |              |            |
| rules, regulations, and  |      |       |              |            |
| directives he/she may be |      |       |              |            |
| sent home at the         |      |       |              |            |
| discretion of the        |      |       |              |            |
|                          |      |       |              |            |
| project officer,         |      |       |              |            |
| encampment commander or  |      |       |              |            |
| activity director at     |      |       |              |            |
| **parental or unit       |      |       |              |            |
| expense.**               |      |       |              |            |
|                          |      |       |              |            |
|                          |      |       |              |            |
|                          |      |       |              |            |
| \_\_\_\_\_\_\_\_         |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_               |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_   |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |              |            |
|                          |      |       |              |            |
| **ACTIVITY/LOCATION**    |      |       |              |            |
| DATE UNIT COMMANDER'S    |      |       |              |            |
| SIGNATURE                |      |       |              |            |
+--------------------------+------+-------+--------------+------------+

**CAWGF150 (Version 1.03 -- 08/08) Replaces CAWGF31 which is obsolete
mmp-ajg**

<table>
<colgroup>
<col style="width: 33%" />
<col style="width: 1%" />
<col style="width: 15%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 17%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10">MEDICAL INFORMATION (FOUO) - TO BE COMPLETED BY ALL
APPLICANTS</td>
</tr>
<tr class="even">
<td colspan="5"><p>NAME OF PARTICIPANT (Last, First Middle Initial)</p>
<p>     </p></td>
<td colspan="3"><p> CADET</p>
<p> SENIOR</p></td>
<td><p> MALE</p>
<p> FEMALE</p></td>
<td><blockquote>
<p>CAPID</p>
</blockquote>
<p>     </p></td>
</tr>
<tr class="odd">
<td><p>ACTIVITY</p>
<p>     </p></td>
<td colspan="5"><p>LOCATION</p>
<p>     </p></td>
<td colspan="4"><p>DATES</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10"><strong>DO YOU CURRENTLY USE ANY MEDICATION? (Including
eye drops)</strong> NO YES (List any medication taken and the reason in
the remarks section.)</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>HAVE YOU BEEN INVOLVED IN AN ACCIDENT
REQUIRING<br />
MEDICAL TREATMENT IN THE PAST FIVE YEARS?</strong> NO YES (Explain the
extent of your injuries and treatment required in the remarks
section.)</td>
</tr>
<tr class="even">
<td colspan="10"><p><strong>MEDICAL TREATMENT WITHIN THE PAST FIVE
YEARS</strong></p>
<p><strong>OTHER THAN REGULAR OFFICE VISITS OR PHYSICALS?</strong> NO
YES (Explain the extent of your injuries and treatment required in the
remarks section.)</p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>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.)</p>
<table>
<colgroup>
<col style="width: 23%" />
<col style="width: 9%" />
<col style="width: 24%" />
<col style="width: 9%" />
<col style="width: 23%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td>1. Tuberculosis</td>
<td> N Y</td>
<td>10. Knee trouble (locking, giving out, pain, etc.)</td>
<td> N Y</td>
<td>19. Period of unconsciousness or concussion</td>
<td> N Y</td>
</tr>
<tr class="even">
<td>2. Asthma or breathing problems related to exercise, weather,
pollens, etc.</td>
<td> N Y</td>
<td>11. Knee or foot surgery</td>
<td> N Y</td>
<td>20. Heart trouble or murmur</td>
<td> N Y</td>
</tr>
<tr class="odd">
<td>3. Shortness of breath</td>
<td> N Y</td>
<td>12. Any need to use corrective devices such as prosthetic devices,
braces, back supports, lifts, etc.)</td>
<td> N Y</td>
<td>21. Nervous trouble (anxiety or panics attacks)</td>
<td> N Y</td>
</tr>
<tr class="even">
<td>4. Wheezing or problems with wheezing</td>
<td> N Y</td>
<td>13. Stomach, liver, intestinal trouble, or ulcer</td>
<td> N Y</td>
<td>22. Depression or excessive worry</td>
<td> N Y</td>
</tr>
<tr class="odd">
<td>5. Been prescribed or used an inhaler</td>
<td> N Y</td>
<td>14. High or low blood sugar</td>
<td> N Y</td>
<td>23. Inability to stand, sit, kneel, lie down, etc.</td>
<td> N Y</td>
</tr>
<tr class="even">
<td>6. Ear, nose, or throat trouble</td>
<td> N Y</td>
<td>15. Adverse reaction to serum, food, insect sting/bites, or
medicine</td>
<td> N Y</td>
<td>24. Any drug or narcotic habit</td>
<td> N Y</td>
</tr>
<tr class="odd">
<td>7. Painful shoulder, elbow, or wrist (pain, dislocation, etc.)</td>
<td> N Y</td>
<td>16. Frequent or severe headaches</td>
<td> N Y</td>
<td>25. Attempted suicide</td>
<td> N Y</td>
</tr>
<tr class="even">
<td>8. Impaired use of arms, legs, hands, or feet</td>
<td> N Y</td>
<td>17. Seizures or convulsions; epilepsy</td>
<td> N Y</td>
<td><p>26. Severe menstrual cramps</p>
<p><em><strong>(Females only)</strong></em></p></td>
<td> N Y</td>
</tr>
<tr class="odd">
<td>9. Chronic or recurring injuries</td>
<td> N Y</td>
<td>18. Motion sickness</td>
<td> N Y</td>
<td>27. Are you currently in good health</td>
<td> N Y</td>
</tr>
</tbody>
</table></td>
</tr>
<tr class="even">
<td colspan="3"><p>IMMUNIZATIONS</p>
<p> Up-to-Date Exceptions:      </p></td>
<td colspan="7">MEDIC ALERT<sup>®</sup> ID NUMBER (If worn):      </td>
</tr>
<tr class="odd">
<td><p>FAMILY / PRIMARY PHYSICIAN</p>
<p>     </p></td>
<td colspan="5"><p>Address</p>
<p>     </p></td>
<td colspan="4"><p>Phone</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>MEDICAL INSURANCE INFORMATION</p>
<p>COMPANY:</p>
<p>     </p></td>
<td colspan="6" rowspan="2"><p><strong>INSTRUCTIONS FOR
CAPF150-MED)</strong></p>
<p><em><strong>Completed Medical Information Forms are <u>F</u>or
<u>O</u>fficial <u>U</u>se <u>O</u>nly (FOUO).</strong></em> Information
gathered in this form shall not be accessed by anyone without a
need-to-know, such as: project officers, activity commanders, medical
officers and physicians. The project officer/commander is responsible to
properly protect this sensitive medical information.</p></td>
</tr>
<tr class="odd">
<td colspan="4"><p>POLICY NUMBER:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Emergency Contact During Activity – Parent, Guardian,
or closest relative to be contacted in case of emergency</p>
<p>     </p></td>
<td colspan="5"><p>Daytime Phone – MUST be available during activity</p>
<p>     </p></td>
<td colspan="3"><p>Evening Phone – MUST be available during activity</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>REMARKS (Please include any drug or food allergies
and all prescription or OTC medication. Describe what the medication is
treating and severity of food allergies, if any. This information is
very important to treating physicians).</p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
</tr>
</tbody>
</table>

**CAWGF150-MED Version 1.03 -- 08/08) FOUO Replaces CAWGF31 which is
obsolete mmp-ajg**