#### National Blue Beret 

# EMERGENCY NOTIFICATION INFORMATION

**& MEDICAL RELEASE FOR A MINOR**

Dear Parent / Guardian and CAP Members,

Safety is of paramount importance within the Civil Air Patrol and the
Blue Beret activity. We are diligent with safety precautions, meetings,
briefings and inspections. However, accidents can occur, despite the
most careful planning.

Accompanying this letter is a request for emergency contact information
and a release for treatment. Please list those individuals we need to
contact in an emergency situation. You may list not only home phone
numbers, but work, cellular, pager and all other numbers as well. Should
an emergency occur, we will attempt to notify you before any action is
taken; however, if an event occurs which requires immediate attention
and we are unable to contact you at the listed numbers, your signature
on this release allows us to get emergency medical or dental treatment
for your child.

Please be certain to list all allergies, illnesses, restrictions,
special health care needs (diabetes, epilepsy, etc.) and all
medications. All medicines, prescription or over-the-counter, that are
brought to this activity must be in the original container with written
instructions, and will be surrendered to the medical officer or
commandant upon arrival. **[CAP is a zero tolerance
organization]{.underline}**. No unmarked medications, drugs, or alcohol
may be in the possession of a cadet during any CAP related activity. No
hazardous material or weapons will be allowed.

In the event over-the-counter medication, such as Tylenol or a remedy
for diarrhea/constipation, is requested by your child or suggested by
the medical officer, we prefer your permission to provide. Again, your
signature on the following form gives us this permission.

If information changes between the time you submit this form and the
activity, please submit an updated release; otherwise we will consider
this returned form accurate and complete.

We appreciate your cooperation, understanding and assistance. Please
return the completed form to the address provided in the welcome letter.
If there is a concern, contact us. We agree to keep the provided
information confidential and will release this data only when
circumstances make it necessary.

Name of
member\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CAP Serial #\_\_\_\_\_\_\_\_\_\_

Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Phone \# (\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Parents/guardians names
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Physicians
name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone
\# (\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_

Insurance carrier
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Insurance plan or group \#
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

List any special health care concerns, restrictions, medical conditions,
allergies, diseases or medicines/prescriptions used (i.e., allergic
reactions, insulin dependent, food sensitivities):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Over-the-counter medications may be provided:

\_\_\_\_\_ yes \_\_\_\_\_ no

Provide first aid - \_\_\_\_\_ yes \_\_\_\_\_ no

Individuals to contact in case of emergency/alternate contact points:
(ie., relatives, work #'s or persons that may know your whereabouts,
pager/cellular #)

### Name Relationship Phone \# 

I/We hereby authorize the Civil Air Patrol to provide transport and care
for my son or daughter to any medical or dental facility or hospital for
emergency or necessary care. I accept the financial responsibility for
this treatment. This authorization continues in effect until cancelled
in writing, a new and updated version of this form is submitted, or
activity is completed.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

Parent/guardian signature Parent/guardian signature Date