jclc packet quick-fill guide dated 01 jul 16 · 2019. 11. 10. · jclc _____ packet quick-fill...

JCLC ____________ PACKET QUICK-FILL GUIDE DATED 01 JUL 16

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1. INSTRUCTIONS: COMPLETE THE FOLLOWING INFORMATION. THIS INFORMATION WILL

POPULATE DATA FIELDS ACROSS THE ENTIRE JCLC PACKET! ALL SIGNATURES MUST BE

COMPLETED BY CADETS, PARENTS, PHYSICIANS AND/OR SAIs AND AIs AS APPROPRIATE.

2. INFORMATION FIELDS (FILL IN THE FOLLOWING):

A. CADET NAME (LAST, FIRST, MI): ________________________________________ (EX. WASHINGTON, GEORGE A.)

B. CADET HOME ADDRESS:

(1) STREET: _____________________________________

(2) CITY/TOWN: ______________________________________

(3) STATE: __________________________

(4) ZIP CODE: _____________________________

(5) COUNTY YOU LIVE IN: _________________________________

B. NAME OF YOUR SCHOOL: __________________________________________________ (EX. OVERBROOK)

C. SAI NAME (LAST, FIRST, MI): __________________________________________ (EX. PATTON, GEORGE S.)

D. AI #1 NAME (LAST, FIRST, MI): _________________________________________ (EX. RYAN, MICHAEL J.)

E. TODAY’S DATE: ________________________ (EX. 25 MARCH 19)

F. PARENT / GUARDIAN INFO:

(1) PARENT/GUARDIAN NAME: (LAST, FIRST, MI): ______________________________ (EX. SIMPSON, HOMER Q.)

(2) ADDRESS:

(a) STREET: _____________________________________

(b) CITY/TOWN: ______________________________________

(c) STATE: __________________________

(d) ZIP CODE: _____________________________

(3) HOME PHONE #: _______________________________

JCLC ____________ PACKET QUICK-FILL GUIDE DATED 01 JUL 16

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(4) WORK #: _____________________________________

(5) CELL #: _______________________________________

G. EMERGENCY CONTACT INFO:

(1) NAME: (LAST, FIRST, MI): ______________________________ (EX. REAGAN, NANCY)

(2) RELATIONSHIP TO CADET: _______________________________ (EX. AUNT)

(3) ADDRESS:

(a) STREET: _____________________________________

(b) CITY/TOWN: ______________________________________

(c) STATE: __________________________

(d) ZIP CODE: _____________________________

(4) HOME PHONE #: _______________________________

(5) WORK #: _____________________________________

(6) CELL #: _______________________________________

H. JCLC START DATE: __________________________ (EX. 21 JUN 18)

I. JCLC END DATE: ____________________________ (EX. 21 JUN 18)

J: CURRENT YEAR: ______________________ (EX. 2018)

NOTE: THIS FORM IS NOT PART OF THE OFFICIAL JCLC PACKET.

Overbrook JROTC

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Overbrook JROTC

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DO NOT TYPE IN ANY INFORMATION INTO THESE FORMS BEYOND THE BOTTOM OF THIS PAGE! ALL YOU NEED TO DO NOW IS...(1) SAVE THIS DOCUMENT AS A PDF FILE (EXAMPLE: JCLC 2017 FLOOD), THEN PRINT IT AND GET THE SIGNATURES, STAMPS, ETC. THAT YOU NEED!

JCLC Adventure South MOI 2016

FORM 1: JCLC 2017 PACKAGE CHECKLIST(Filled in by SAI/AI)

PRINT STUDENT NAME (LAST, FIRST): _________________________________________

SCHOOL: _________________________________________

As the Cadet's SAI/AI, I certify that:

a. I have reviewed all paperwork and it is complete, legible and accurate.

b. All basic requirements for attendance at JCLC have been briefed to the cadet

c. Cadet has passed all physical fitness requirements

d. This cadet to my knowledge has not been diagnosed with asthma,

does not use an inhaler or any device to aid in breathing, and is not taking any

medication to prevent or reduce the severity of asthma symptoms.e. A Physician (MD or DO) has signed and stamped Form 5, indicating that

the cadet is cleared medicallyto participate in JCLC 2017.

f. A copy of the Cadet's Health Insurance Card is attached to this packet, verifying

that the cadet has health insurance coverage.

Directions: SAI/AI, please intial each block below after the document has been reviewed

and completed. Please assemble all documents in the order of the form numbers, i.e.,

Form # 1 is first and Form # 13 is last)

Documents SAI/AI InitialsPart I Form 1: JCLC Package Checklist

Admin Form 2: Cadet & Parent/Guardian Agreement

Form 3: Cadet Information

Form 4: Cadet Visitor Information

Part II Form 5: JCLC Overview for Parents & Physicians

Medical Form 6: Over-the-Counter Medication Authorization

Form 7: Consent to Medical Treatment

Form 8: JCLC Power of Attorney (MEDICAL)

Form 9: Medical Insurance Card (copy the front & back)

Part III Form 10: Standards, Contraband & Equipment

Liability Form 11: Physical Fitness & Swimming Statement

Form 12: Contract of Release & Waiver of Liability

Form 13: Covenant Not to Sue

Part IVClothing

SAI/AI Signature: _________________________________________________

Printed Name: ___________________________________________________

DATE: ________________________

JCLC ADVENTURE SOUTH 2017

NOMINATION

REQUIRED DOCUMENTS

Form 14: JCLC Cadet Packing List

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JCLC Adventure South MOI 2016 v1 draft

Print Cadet's Name (Last, First): _________________________________________________

School Name:______________________________________________________________________

1. I agree that:

DocumentsPart I Form 1: JCLC Package Checklist

Admin Form 2: Cadet & Parent/Guardian Agreement

Form 3: Cadet Information

Form 4: Cadet Visitor Information

Part II Form 5: JCLC Overview for Parents & Physicians

Medical Form 6: Over-the-Counter Medication Authorization

Form 7: Consent to Medical Treatment

Form 8: JCLC Power of Attorney

Form 9: Medical Insurance Card (copy the front & back)

Part III Form 10: Standards, Contraband & Equipment

Liability Form 11: Physical Fitness & Swimming Statement

Form 12: Contract of Release & Waiver of Liability

Form 13: Covenant Not to Sue

Part IVClothing

b. Report to JCLC 2017:1. With all required articles of uniform & equipment per Cadet Packing List.2. In compliance with JROTC grooming regulations3. With no existing medical problems, and in good physical condition.

c. Follow all orders given by the JCLC cadre.

Cadet Signature: __________________________________

Date: __________________________________________

2. I understand that not meeting the above requirements may result in my early dismissal from JCLC with parents providing arrangements for immediate cadet pickup.

FORM 2 -- CADET & PARENT/GUARDIAN AGREEMENT (Page 1 of 2)

Form 14: JCLC Cadet Packing List

(Filled in by Cadet & Parent/Guardian)

CADET AGREEMENT

a. I will provide my SAI/AI with the following items by May 1st, 2017, so that I am eligible to attend JCLC 2017.

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JCLC Adventure South MOI 2016 v1 draft

Directions: Please initial each block below after reading it signifying that you understand.

I understand the following to be true for my Cadet:

Parent Initials Important InformationHe/she will be supervised/chaperoned during all activities throughout the six day period.

He/she has medical insurance and a copy of the front & back of our current medical insurance

card is included with the application submission.

Cadets are not permitted to have their cell phones during the training. They may be permitted to

use them during the evening hours.

He/she will be involved in a six day course of instruction that will challenge him/her as an

individual and as a team, with safety always coming first.

He/she will have meals and lodging provided the entire six days.

He/she will be involved on a daily basis with activities planned for them, which does not require

any money. They will be going to Clementon Park (Amusement Park that contains both rides

and water activities) for half a day. You may provide your son/daughter with some souvenir

money.

He/she will be provided medical attention as needed only on a reimbursable basis. Emergency

treatment will be handled at the nearest facility, but this treatment will be billed to the

parent/guardian/cadet's medical insurance.

By voicing his/her desire, a cadet has the right to withdraw from JCLC summer camp at any

time, and will immediately be taken out of the training situation, and kept under supervision until

departure to return home.

I am responsible for picking up my cadet if it is determined that he/she must depart from camp

prior to its graduation ceremony.

If it is determined that your cadet is disregarding rules and regulations, or not participating in

activities, they may be pulled out of training, and sent home at the parent/guardian's expense as

soon as arrangements can be made.

He/she will receive the best possible six days of training with an emphasis on safety.

PARENT! DID YOU READ AND INITIAL ALL ITEMS ABOVE?

Parent/Guardian Signature: _______________________________

Date: __________________________________________

PARENT/GUARDIAN AGREEMENT

FORM 2 -- CADET & PARENT/GUARDIAN AGREEMENT (Page 2 of 2)

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FORM 3 -- CADET INFORMATION

STATEMENT REQUIRED BY PRIVACY ACT OF 1974

1. AUTHORITY: Title 10, U.S. Code 2102 2. PRINCIPAL PURPOSE(S): To gather information, emergency points of contact, and

statement of physical condition of JROTC Cadets attending JCLC. 3. ROUTINE USES: Normal Personnel Actions – Disclosures of information may be provided to

proper authorities in actions regarding medical treatment, legal actions, investigation of accidents, and preparation of statistics and training records resulting from JCLC.

4. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Disclosure is voluntary. Failure of Cadet to complete form will disqualify JROTC Cadet from participating in JCLC.

1. Cadet Name:_______________________________________________________ (Last Name, First, MI)

2. Name of School: ________________________________ 3. I will attend JCLC at Joint Base McGuire-Dix-Lakehurst from ______________ to _____________, ___________. 4. Parent/Guardian Name:___________________________________________

(Last Name, First, MI) Address: ___________________________________________________________ Work #: ________________ Home #: ________________ Cell #: ______________ 5. Family Doctor Name:_________________________________________________________

(Last Name, First, MI) Address: _____________________________________________Office #: _______________ 6. Emergency Contact: ______________________________Relationship:_________________

(Last Name, First, MI) Address: _______________________________________________________________ Work #: ________________ Home #: ________________ Cell #: ______________ Parent Signature _______________________________________Date: ____________

PRINT STUDENT NAME (LAST, FIRST): ____________________________________

SCHOOL: ________________________________________

EVENTS PARENTS / GUESTS MAY PARTICIPATE IN:

1. JCLC CAMP BBQ, DOUGHBOY FIELD - _______________JUN 16 (TIME: __________)START TIME / END TIME

2. JCLC GRADUATION, ______________________ - ________________ (DAY) OF WEEK, DATE) START TIME / END TIME

Parent/Guardian Signature: _______________________________

Date: __________________________________________

Date of Birth (MM/DD/YYYY)GENDERFIRST NAMELAST NAME

FORM 4: CADET VISITOR / BASE ACCESS ROSTER

(DAY) OF WEEK, DATE)

Instructions:

1. Your JROTC program/school may or may not provide bus transportation from your high school to the JCLC graduation. If you are non-military (don’t

have a military ID card of any kind) and your JROTC program/school provides a bus for you to ride to JCLC graduation, you DO NOT need to complete this form.

2. If your JROTC program/school is NOT providing bus transport from your high school to JCLC graduation and you will be driving your personally-owned vehicle (POV), you MUST provide the information below for EACH ADULT VISITOR.

MIDDLE INITSTATE OF

RESIDENCE Drivers License Number

Overbrook JROTC

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FORM 5 -- JCLC OVERVIEW FOR PARENTS AND PHYSICIANS

TO ASSIST THEM IN MAKING DECISIONS ON WHETHER CADETS SHOULD ATTEND JCLC

SIGNATURES REQUIRED

(Page 1 of 4 pages)

A brief sketch of JROTC Summer Camp (JCLC Adventure) is presented as an aid to adults in making Health/Medical decisions about their cadets participating in the JROTC Summer Encampment. Please refer to the Master Training Calendar attached.

Note the rigor, intensity, quantity and sustained continuity of the JCLC program

activities/events. Almost every day is a very full, long, intensive, arduous and demanding life and training experience. All programs are adventurous and challenging, exciting and stimulating but involve stress, frustration, competition, teamwork, problem solving and critical thinking skills, citizenship and leadership, organization, communication, management, and individual interpersonal relations. Cadets are rotated into leadership positions and evaluated on their performance. Everything is oriented at growth and fun.

JCLC is basically focused at responsibility, accountability, discipline and control, respect

and courtesy, meeting standards, accepting duly constituted authority, following established leaders, and being a winner through pride, competence, esteem, dignity and confidence. Cadets participate in individual as well as group team building activities.

The Fort Dix post contains trees, flowers, grass and sand. Pollen, blowing dust, etc. are

environmental aspects to be encountered. Weather is usually hot and humid with daily temperatures typically in the 85-90 degree range. Frequently, there are 90-95 temperature days when the human body is continually sweating requiring sustained water replenishment. Sometimes, there are 2-4 days of extreme high daily temperatures in a row and the evening temperatures may not fall to cool the air. Thus, the barracks may become hot. The barracks are cooled by central air, allowing some relief from the heat.

Cadets reside in a 3-story building in rooms consisting of 2-8 people per room in bunk

beds. All males are on one floor, while females are on another floor. All showers and rest room facilities are common and shared; males in male restrooms and females in female restrooms. Cadets are continuously supervised by Cadre to include their JROTC Instructor(s) 24 hours a day. Additionally, an adult will remain with any cadet for required medical treatment at a military Aid Station and/or civilian hospital.

JCLC is strenuous and cadets are not generally physically fit / acclimated to the NJ heat

and humidity in terms of military-cadet JCLC lifestyle, training events, field craft, outdoor living/camping and survival, and soldier-cadet skills. Additionally, cadets usually have a poor understanding of and are not accustomed to hydration, as are experienced woodsman, campers and soldiers to endure the Fort Dix Summer weather.

Thus, the mental modality needs education and the emotional attitude needs continual

positive reinforcement to Drink, Drink, and Drink.


FORM 5 -- JCLC OVERVIEW FOR PARENTS AND PHYSICIANS (Page 2 of 4 pages)

JCLC Adventure consists of many strenuous and physically demanding activities. Cadets are going to be involved in a 6-day overnight, residential Army Junior Reserve Office Training Corps intensive CITIZENSHIP & LEADERSHIP encampment (on a secure Army post). Listed below is a sample of the types of activities the cadets will be involved in. While at JCLC, Cadets will be under limited medical supervision, consisting of two nurses and four EMTs. For medical emergencies, Fort Dix has dedicated medical personnel available 24/7. Cadets should not come to JCLC if they have a pre-existing medical condition that can be exacerbated by the below listed activities. Physical Events include:

Obstacle Course (running, climbing, jumping, bouncing)

Rappelling (climbing, jumping, bouncing off wall, heights of 60 feet)

Aquatics Swimming & Treading water (water survival test, drownproofing, floating, underwater, jumping into water)

Leader Reaction Course (climbing, hanging, pushing & pulling, building human ladder, swinging, lifting)

Sports-A-Rama (mixture of various sports and races/relays in competition near end of JCLC)

Land Navigation/Orienteering (extended period of running and walking through woods and brush)

Confidence Course (climbing, dodging, pushing, jumping, leaping, swinging, descending and ascending, moving up/down/along vertical and horizontal ladders by hanging with arms)

COPE Course (low impact team building events done on the ground level)

Ropes Course (climbing, hanging, pushing & pulling, lifting, moving along horizontal ropes, descending and ascending)

Rock Wall (climbing, hanging, pushing & pulling, descending and ascending) Physical Activities include: Running, Jumping, Climbing & Descending, Hanging, Pulling & Pushing, Rolling, Bouncing, Stretching, Exercising, Swimming, Marching. Sitting and Standing for long periods, etc. -–a full and complete regimen of physically demanding and challenging activities.

Cadets strongly desire to attend JCLC and succeed to graduate. All JROTC teachers want cadets to participate and gain the benefits and advantages of JCLC; however, we must all agree that Cadets must be in excellent health/medical condition with no problems which would impair/impede JCLC involvement, cause self-harm or negatively interfere in other cadets/adults participation/safety.

JCLC completely operates on a risk management process and all activities are

evaluated on the cadet participant and the event features, i.e., water, height, movement, teamwork, etc. Cadets must be fully capable of immediately following instructions especially in safety related instances. Cadets unable to promptly respond to instructions, especially safety focused, will not attend JCLC. This Overview of JCLC is, at best, limited in scope.



(Page 3 of 4 pages)

PARENT / GUARDIAN STATEMENT OF UNDERSTANDING

JCLC PARTICIPATIONS AND

MEDICALLY DISQUALIFYING / PRE-EXISTING CONDITIONS

I fully understand all of the above information concerning training events and activities my student will have the opportunity to participate in while attending JCLC. Additionally, I understand that certain medical conditions can / will disqualify my student from attending JCLC. These conditions include but are not limited to: asthma, diabetes, severe allergies; certain digestive tract ailments; heart, lung, liver, kidney disorders or ailments; sensory organ disorders or ailments; skin disorders or ailments; psychological disorders or other physical/mental illnesses, ailments and disorders. It is both my responsibility and my student’s responsibility to be forthright in notifying JROTC instructors of any and all pre-existing medical conditions. PARENT/GUARDIAN SIGNATURE _____________________________________ DATE __________________________

GO TO NEXT PAGE FOR PHYSICIAN SIGNATURE AMD STAMP



(Page 4 of 4 pages)

PHYSICIAN’S CONFIRMATION:

After examining student (NAME HERE) ____________________________________ and reviewing their medical history, the student is (initial one of the below statements):

a. ______ CLEARED for participation in JROTC JCLC Summer Camp 2017 without restrictions. b. ______ NOT CLEARED for participation in JROTC JCLC Summer Camp 2017 until evaluation/treatment of:

PHYSICIAN’S SIGNATURE AND OFFICE STAMP

NOTE: FAILURE TO HAVE THIS FORM SIGNED, DATED AND STAMPED BY A CERTIFIED PHYSICIAN (MUST BE AN MD OR DO) WILL PRECLUDE THE CADET’S ATTENDANCE OF JCLC. PHYSICIAN SIGNATURE AND STAMP: ___________________________DATE: __________ PHYSICIAN NAME (PRINT)_______________________________________________

(NAME OF PHYSICIAN PRINTED ABOVE AND/OR OFFICE STAMP MUST CLEARLY STATE “MD” OR “DO”)

OFFICE ADDRESS: _____________________________________________________ OFFICE PHONE #: _______________________________________________________

PHYSICIAN OFFICE STAMP HERE


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FORM 6 -- OVER-THE-COUNTER MEDICATION AUTHORIZATION STUDENT NAME: ______________________________________________ SCHOOL: ______________________________________________ INSTRUCTIONS FOR PARENTS / GUARDIANS: Please initial next to the response which indicates the actions you want JCLC 2017 Cadre and Medical Staff to abide by when it comes to giving your Cadet over-the-counter medications. ________ I DO NOT give the JCLC Camp nurses permission to administer over-the-counter medication to my son/daughter at any time during JCLC 2015. ________ I DO give the JCLC Camp nurses permission to administer over-the-counter medication listed below that I have initialed at any time during JCLC 2015: ________ (1) Tylenol (Acetaminophen) 325 mg x2 tabs. PO every 4 hours PRN for

pain or fever ________ (2) Motrin (Ibuprofen) 400 mg PO every 4 hours PRN for pain or fever ________ (3) Benadryl 25 mg PO every 4 hours PRN for signs & symptoms of

allergies ________ (4) Claritin 10 mg PO every 4 hours for signs & symptoms of allergies ________ (5) _______________________________________________________

(add other medications and dosages)

NOTE: If Parent initials off “I DO NOT GIVE PERMISSION”, then a doctor’s signature or stamp is NOT REQUIRED. OTHERWISE, DOCTOR SIGNATURE AND STAMP IS REQUIRED BELOW.

PARENT NAME: ______________________________________________ PARENT SIGNATURE: _________________________________________ FAMILY USES THIS PHARMACY CHAIN: Pharmacy Name _________________________________________________ Address _____________________________________________________________________ Phone Number _________________________________________

GO TO NEXT PAGE FOR PHYSICIAN STAMP AND SIGNATURE


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FORM 6 -- OVER-THE-COUNTER MEDICATION AUTHORIZATION PHYSICIAN SIGNATURE AND STAMP: ___________________________DATE: __________ PHYSICIAN NAME (PRINT)_______________________________________________

(NAME OF PHYSICIAN AND/OR OFFICE STAMP MUST CLEARLY STATE “MD” OR “DO”)

OFFICE ADDRESS: _____________________________________________________ OFFICE PHONE #: _______________________________________________________

PHYSICIAN OFFICE STAMP HERE


FORM 7 -- CONSENT TO MEDICAL TREATMENT

(Page 1 of 2 pages)

STATEMENT REQUIRED BY PRIVACY ACT OF 1974

(1) AUTHORITY: TITLE 10, U.S. CODE 2102 (2) PRINCIPAL PURPOSES: A statement authorizing medical care in civilian or

government medical facilities while attending or traveling to and from JCLC. (3) ROUTINE USES: Normal personnel actions: Disclosure of information may be provided

to proper authorities in actions regarding medical treatment, legal actions as a result of injury or death, and investigation of accident resulting from JCLC.

(4) MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary. Failure to complete form will disqualify JROTC Cadet from participating in specific voluntary training exercises.

Printed Cadet Name: ___________________________________________ School: ___________________________________________ 1. STATE OF PHYSICAL CONDITION. To the best of my knowledge, my son/daughter/ward is in good physical condition. Participation in JCLC, in my opinion, will not have an adverse effect on his/her health and well-being. I will immediately inform the School and Senior Army Instructor in writing of any changes.

2. MEDICAL CONSENT. a. I give my consent for my son/daughter to be treated in an Army Hospital, or any other government or civilian medical facility, near or en-route to Joint Base McGuire-Dix-Lakehurst, New Jersey, while attending or traveling to or from JCLC __________from _______________to 01 July, _________. b. This consent encompasses all procedures and treatments as are found to be necessary or desirable, in the judgment of the professional staff of any of the above-named medical facilities. I understand that this consent is of a general nature and accordingly list the following exceptions to this consent (if no exceptions write “No Exceptions”) _______________________, ____________________, ________________________


FORM 7 -- CONSENT TO MEDICAL TREATMENT

(Page 2 of 2 pages) 3. MEDICAL CONDITIONS:

a. He/she is on the following medications and dosages: _______________________, ____________________, ________________________

b. He/she has the following allergies, asthma or reactions to bites and stings and/or takes the following medications and dosages for it:

_______________________, ____________________, ________________________ c. Students that are found to have previous history of any type illness, past injury,

and/or symptoms of suspected medical ailment, will be returned home if treatment is needed or desired.

4. CONSENT WITHDRAWAL: It is understood that this consent can be withdrawn in writing or orally at any time. PARENT NAME: _____________________________________________ PARENT SIGNATURE: ____________________________________________________ DATE: _____________________


FORM 8 -- JCLC POWER OF ATTORNEY (MEDICAL)

KNOW ALL MEN BY THESE PRESENTS: That I, ____________________________________ (Parent/guardian Name)

a legal resident of ___________________, and residing at _____________________________, (Town) (Street) ________________________, ________________, have made, constituted and appointed, and

(Town) (State) by these presents do make, constitute and appoint the following persons to be my true and lawful attorneys:

___________________________________________________ (name of individual granted POA) ___________________________________________________ (name of individual granted POA) ___________________________________________________ (name of individual granted POA)

to act as follows, GIVING AND GRANTING unto my said attorney full power to authorize medical treatment or examination of my dependent minor child _________________________________, (First, MI, Last Name of Cadet) as authorized by paragraph 4-51, Army Regulation 40-3.

FURTHER, I do authorize my aforesaid attorney in fact to perform all necessary acts in

the execution of the aforesaid authorizations with the same validity as I could effect if personally

present. Any act or thing lawfully done here under by my said attorney shall be binding on myself

and my heirs, legal and personal representatives, and assigns.

PROVIDED, however, that all business transacted here under for me or for my account

shall be transacted in my name, and that all endorsements and instruments executed by my said

attorney for the purpose of carrying out the foregoing powers shall contain my name, followed by

that of my said attorney and the designation “attorney-in-fact”.

FURTHER, unless sooner revoked or terminated by me, this special Power of Attorney

shall become NULL and VOID after July 1st, ___________.

IN WITNESS WHEREOF, I have here unto set my hand and seal this_____________ (Day) day of _____________, ________. (Month)

Parent/Guardian Signature ______________________________________________________

GO TO NEXT PAGE FOR NOTARY PUBLIC SEAL

Overbrook JROTC

Text Box

LAST NAME, FIRST NAME, MI


ACKNOWLEDGEMENT

(by Civilian Notary Public)

STATE OF ___________________________ COUNTY OF________________________

I, _________________________________, do hereby certify that I am a duly (NAME OF NOTARY) commissioned, qualified, and authorized notary public in and for the State of

_______________________; that _________________________ grantor, in the foregoing (STATE OF RESIDENCE) (NAME OF PARENT)

Power of Attorney here to annexed, who is personally well known to me as the person who executed the fore going Power of Attorney, appeared before me this day within the territorial limits of my authority, being first duly sworn, acknowledged that he executed said instrument after the contents thereof had been read and duly explained to him, and that such execution was his free and voluntary act and deed for the uses and purposes there in set forth. IN WITNESS WHEREOF, I have here unto set my hand and affixed my official seal the _________________ day of ____________________, ________________. (EX. 1st) (month) (year)

________________________________________

(NOTARY SIGNATURE)

NOTARY PUBLIC

STAMP / SEAL HERE


FORM 9 – PROOF OF CADET HEALTH INSURANCE

INSTRUCTIONS TO PARENTS: Cadets must provide a photocopy (color or black-and-white, FRONT AND BACK) of their health insurance card with this JCLC packet in order to attend JCLC.

FAILURE TO PROVIDE A COPY (FRONT AND BACK) OF A VALID HEALTH INSURANCE CARD WILL PRECLUDE THE STUDENT / CADET FROM ATTENDING JCLC.

JROTC CADRE INSTRUCTIONS: ATTACH COPY (FRONT AND BACK) OF VALID CADET HEALTH INSURACE CARD HERE.


FORM 10 -- STANDARDS, CONTRABAND AND EQUIPMENT ACCOUNTABILITY (Page 1 of 2 pages)

1. JCLC ADVENTURE STANDARDS:

I, _____________________________________________ have been fully informed about

(Print Last Name, First Name, MI of Cadet)

JCLC Adventure particularly as it pertains to the STANDARDS of CIVIC VALUES, DISCIPLINE

& ETHICS.

I have been briefed and read the issued JCLC material and talked with my fellow cadets,

military teachers and parents/guardians about these rules of behavior and performance,

medical, contraband and safety. I understand my JCLC role as a cadet camper engaged in

CITIZENSHIP & LEADERSHIP through FOLLOWERSHIP positions. I realize the importance of

DISCIPLINE, RESPECT & COURTESY and that the STANDARD is very high but attainable

through hard work resulting in achievements opening the doors to opportunity.

I acknowledge I will always do my best at JCLC Adventure and obey the JCLC rules to

the best of my ability. I accept Camp ‘Disciplinary Action’ through the Chain of Command and

know the JCLC Commander has the final and ultimate authority of disenrollment and release

from JCLC should my behavior and/or performance warrant. Dismissal may result in missing

scheduled training activities due to early departure; refunds of JCLC money are not authorized.

The JCLC staff / JROTC Instructor will attempt to contact the cadet’s parents/guardians

in the event of developing problems/troubles or serious situations, especially those involving the

STANDARDS. Parents/Guardians are responsible to immediately retrieve cadets dismissed

from JCLC. Cadets receiving ‘Disciplinary Action’ may forfeit JCLC activities/presentations (no

reimbursements of JCLC payments are authorized).

Incomplete/unsatisfactory/non-submitted JCLC registration forms / fees past due date is

cause for JCLC enrollment denial. Inspections and Searches will be conducted, as

reasonable/appropriate, when necessary. I also understand and will comply with the JCLC

Personal Appearance & Dress, Buddy System, Respect & Courtesy, Discipline, Health &

Medical, Amnesty & Contraband Standards & Rules.


FORM 10 -- STANDARDS, CONTRABAND AND EQUIPMENT ACCOUNTABILITY (Page 2 of 2 pages)

2. CONTRABAND POLICY:

Cadets will NOT bring any contraband to JCLC. Contraband is defined as anything that will

cause harm to others or to oneself, such as, but not limited to, the following items:

Consumption of or possession of alcoholic beverages, tobacco products or drugs

Possession of ammunition of any type at any time, to include ammunition residue and

empty shell casings

Possession of a weapon of any type

3. UNIFORM, EQUIPMENT, SUPPLIES, & MATERIALS RESPONSIBILITY & ACCOUNTABILITY STATEMENT:

I acknowledge receipt of appropriate uniform, clothing and other issues of

government/JROTC property for which I have affixed my signature and date of acceptance of

property. I understand it is my individual, personal responsibility, at all times, and under all

situations, to do my best to maintain and safeguard all US/JROTC government property

entrusted to my care and use. Additionally, I accept accountability for the pecuniary liability to

responsibly reimburse the federal government/JROTC for missing, damaged, destroyed

property, etc. Not due to Fair Wear & Tear. As the parent/guardian of the above

cadet/candidate, I also accept legal responsibility and accountability for the pecuniary liability to

responsively reimburse appropriate authorities in the event my teenager is unable to repay for

non-returned, non-usable US government/JROTC property.

4. PERSONAL CELL PHONES AND OTHER ELECTRONIC DEVICES. Cadets are encouraged NOT to bring personal cell phones and other electronic devices

to camp. If they do bring it to camp, it is brought at their own risk. Camp is NOT responsible for

any personal cell phones or other electronic devices that become lost, stolen, or damaged

during JCLC 2017.

Student Name: ___________________________ Parent Name: _______________________ Student Signature ________________________ Parent Signature ____________________ Date ____________________ Date _________________


FORM 11 -- PHYSICAL FITNESS AND SWIMMING STATEMENT

PART 1 - JROTC CADRE STATEMENT OF CADET’S PHYSICAL FITNESS: I, the school SAI/AI, certify that Cadet ______________________________________has taken (Last Name, First Name, MI) part in a physical conditioning program and has passed the Cadet Challenge or comparable

test. I am responsible for returning the cadet home expeditiously, in the event the cadet is not

physically fit. In my judgment, this cadet is physically capable of engaging in the strenuous

activities required at JCLC. To the best of my knowledge, this cadet has no health problems

that would preclude attendance at JCLC.

SIGNATURE OF SAI / AI: ________________________________ DATE: _______________ PART 2 - PARENT(S) STATEMENT OF CADET’S LEVEL OF SWIMMING PROFICIENCY: During JCLC, my student/Cadet, ________________________________________ will be in (Last Name, First Name, MI) and around water. We need to known the level of swimming proficiency of the cadet. I, the parent of the Cadet named above, assess my student’s/Cadet’s swimming proficiency as: NON-SWIMMER / BEGINNER / INTERMEDIATE / ADVANCED (Circle one) Cadet Signature _______________________Parent Signature ______________________ Date __________________ Date _____________________


FORM 12 -- CONTRACT OF RELEASE AND WAIVER OF LIABILITY

(Page 1 of 2 pages) I, ___________________________________, (Participant/Releasor), acknowledge and

(Print Name of Cadet) Agree that I have voluntarily applied to participate in JROTC military-style training

activities (“Training”), which may include any of the following (examples include, but are

not limited to): rock climbing, rappelling, drill and ceremonies (marching and parades),

field training, military maneuvers, water events (such as swimming, boating, rafting or

any event involving water that is not specifically mentioned elsewhere), sports or athletic

events (which may involve rigorous exercise), rope climbing (includes any event

involving a rope that is not specifically mentioned elsewhere), and similar such activities.

I AM AWARE AND ACKNOWLEDGE THAT THE ACTIVITIES IN WHICH I

WILL PARTICIPATE ARE INHERENTLY DANGEROUS. THE INHERENT HAZARDS

OF SUCH ACTIVITIES COULD CAUSE SERIOUS INJURY OR DEATH. I HEREBY

AFFIRM THAT I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH

FULL KNOWLEDGE AND ACCEPTANCE OF ALL DANGERS INVOLVED, AND

AGREE TO ASSUME ANY AND ALL RISKS OF BODILY INJURY, DEATH OR

PROPERTY DAMAGE, WHETHER THOSE RISKS ARE KNOWN OR UNKNOWN. I

AFFIRM THAT I AM IN GOOD HEALTH AND THAT I HAVE NO MEDICAL OR

PHYSICAL CONDITIONS THAT CAN, WILL OR MIGHT PREVENT MY SUCCESSFUL

PARTICIPATION IN ANY TRAINING ACTIVITIES, AND I FURTHER AFFIRM THAT I

PRESENTLY AM COVERED BY AN ADEQUATE HEALTH AND LIFE INSURANCE

POLICIES THAT WILL COVER ANY INJURIES OR DEATH THAT I MIGHT SUFFER

WHILE PARTICIPATING IN ANY TRAINING ACTIVITIES.

In consideration for being permitted by the JROTC school program of 2nd Brigade

ROTC, the 2nd Brigade ROTC, the U.S. Army and any agency or employee of the U.S.

Government (U.S.G.), ________________________, its School District / Board of

Education, the Neptune Township Board of Education, the employees, agents,

instructors, Senior Army Instructors, Army Instructors, and any lessor/owner of the

premises (“Lessor”), or the owner of any of the equipment or facilities (“Affiliated

Individuals or Organizations”) required to participate in any Training and use or be on or

in the premises and facilities wherein or whereon the training will take place, I, the

Participant/Releasor do hereby forever release the JROTC school program of 2nd


FORM 12 -- CONTRACT OF RELEASE AND WAIVER OF LIABILITY

(Page 2 of 2 pages)

Brigade ROTC, the 2nd Brigade ROTC, the U.S.G., the Neptune Township Board of

Education, the Lessor, the employees, agents, instructors, Senior Army Instructors,

Army Instructors, and any lessor/owner of the or any Affiliated Organizations, and their

respective directors, officers, employees, volunteers, agents, contractors, and

representatives (collectively “Releasees”) from any and all actions, claims, or demands

that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal

representatives now have, or may have in the future, for injury, death, or property

damage, related to (i) my participation in these activities, (ii) the negligence or other acts,

whether directly or indirectly connected to these activities, and however caused, by any

Released party, or (iii) the condition of the premises where these activities occur,

whether or not I am then participating in the activities. It is my intent this release shall

bind my assignees, heirs, legatees, distributees, guardians, next of kin, spouse and legal

representatives, who shall also waive any and all rights against who I might have to

make a claim against, sue, or attach the property, personal or public, of any Releasee

(Released party) in connection with any of the matters covered by the foregoing release.

If signed by Parent or Guardian: I verify, affirm and acknowledge that the dangers of the

activities and the significance of this Release and waiver were explained to both myself

and the Participant/Releasee, to my satisfaction, and that both I and the Participant/

Releasee understand and consent to risking them. FURTHER, A REQUIREMENT TO

PARTICIPATE IN JCLC ADVENTURE SOUTH WILL IN THE SIGNING OF THIS

RELEASE SIGNED BY PARTICIPANTS, PARENTS AND GUARDIANS OR ANY

INDIVIDUAL AND/OR ORGANIZATION OF AUTHORITY PARTIES WHICH RELEASED

PARTIES WILL DETRIMENTALLY RELY AS A PRECURSOR/ACCEPT FOR

ATTENDANCE.

_________________________________ ____________________________ Cadet Signature Parent/Guardian Signature Date ____________________ Date _____________________ _____________________________________________ JROTC Instructor Signature __________________________ Date


FORM 13 -- COVENANT NOT TO SUE

I, Cadet ___________________________________________________ do hereby agree that (Cadet Last Name, First Name, MI) in consideration for being allowed to participate in JROTC Cadet Leadership Challenge (JCLC)

at Joint Base-McGuire-Dix-Lakehurst, NJ and Neptune Township Board of Education,

conducted by the JROTC school program of 2nd Brigade ROTC, the 2nd Brigade ROTC, United

States Army Cadet Command, an Army supervised activity, and whereas I am doing so entirely

on my own initiative, risk and responsibility; and being fully aware of the risks involved with this

type of training, I hereby RELEASE AND DISCHARGE FOREVER, the JROTC school program

of 2nd Brigade ROTC, the 2nd Brigade ROTC, the United States Army, the Neptune Township

Board of Education, the State of ________________ and _______________________ and all

of it’s officers, agents, instructors, Senior Army Instructors, Army Instructors, volunteers, and

employees, acting officially or otherwise, from any and all claims. Demands, actions, and/or

causes of action, on account of myself OR on account of any injury to me which may occur from

any cause during said activity or continuances thereof, and I do further covenant and agree to

hold the JROTC school program of 2nd Brigade ROTC, the 2nd Brigade ROTC, the said

Government of the United States, the Neptune Township Board of Education, the State of

_______________and __________________________ and all of its officers, agents,

instructors, Senior Army Instructors, Army Instructors, volunteers, and employees, acting

officially or otherwise, from any and all claims. Demands, actions, and/or causes of action, on

account of myself OR on account of any injury to me which may occur from any cause during

said activity or continuances thereof, and I do further covenant and agree to hold the JROTC

blameless for any and all damages which I may cause either intentionally or through my

negligence.

_______________________________________ __________________________________ Signature of Cadet Signature of Parent/Guardian Date _________________________ Date _________________________

check init # REQ CADET PURCHASED OR ACQUIRED ITEMS

1 COMBINATION LOCK (WITH KEY ACCESS) OR KEY LOCK

1-2 DUFFEL BAG

5 UNDERWEAR (SHORTS)

1 SHOWER SHOES (PAIR)

1 ATHLETIC/RUNNING SHOES

3 SHORTS/T-SHIRTS (FOR PT)

5 ATHLETIC SOCKS (PAIRS)

1 SWIM WEAR (MALE - TRUNKS. FEMALE - ONE PIECE)

3 BATH TOWELS (MINIMUM 3)

2 WASH CLOTHS (MINIMUM 2)

xxx PAJAMAS (IF USED) (OPTIONAL)

1 FOOT POWDER (CAN/SPRAY)

1 INSECT REPELLANT (CAN/SPRAY)

1 SUNSCREEN (SPF 30 OR HIGHER)

1 EYE GLASSES (SPARE) (AS REQUIRED)

1 SOAP (BAR/SOFT SQUEEZE)

1 OPTIONAL: SOAP DISH (ONLY IF YOU BRING BAR SOAP)

1 SHAMPOO (RECOMMEND TRAVEL-SIZE)

1 TOOTHBRUSH

1 TOOTHPASTE

1 RAZOR (REQUIRED FOR MALES ONLY)

1 SHAVING CREAM (REQUIRED FOR MALES)

1 DEODORANT

1 COMB/BRUSH

3 HAND SANITIZER (POCKET SIZE)

1 LIP BALM

1 LOUNGE WEAR (SWEATPANTS AND SWEAT SHIRT)

1 LAUNDRY BAG (OR EXTRA PILLOW CASE IN LIEU OF)

JCLC ____________EQUIPMENT LIST / INSPECTION CHECKLIST

CADET ___________________ DATE OF INSPECTION: __________________

check init # REQ CADET PURCHASED OR ACQUIRED ITEMS

XXX PRESCRIPTION MEDICATION(S) (AS REQ)

1 FLASHLIGHT (SMALL)

2 BATTERIES FOR FLASHLIGHT

3+ SPORTS BRA (FEMALES ONLY)

XXX FEMININE HYGIENCE PRODUCTS (FEMALES ONLY - AS REQ.)

1 PILLOW (RECOMMENDED, NOT REQUIRED)

1 PILLOW CASE (RECOMMENDED, NOT REQUIRED)

XXX CELL PHONE (OPTIONAL)

XXX Ipod (optional)

check init # REQ ITEMS TO BE ISSUED BY / TURNED IN TO JROTC CADRE SIZE TURNED IN?

1

CAMELBACK WITH WATER BLIVET, HOSE AND MOUTH PIECE

OR PISTOL BELT WITH 1 QUART CANTEEN (IN LIEU OF

CAMELBAK)

1 ACU RAIN PARKA OR PONCHO

2 ACU COAT (PACK ONE)

2 ACU PANTS ( PACK ONE)

1 ACU CAP

2 SCHOOL NAME VELCRO TAG (1X ACU COAT, 1X PATROL CAP)

1 JROTC VELCRO TAG

1 SUBDUED JROTC VELCRO PATCH (FOR LEFT SHOULDER)

1 SUBDUED SCHOOL VELCRO PATCH (FOR RIGHT SHOULDER)

XXX RAIDER CHALLENGE VELCRO TAB (AS REQUIRED)

1 ACU BELT

5 BOOT SOCKS (PACK 4 PAIR)

5 TAN UNDERSHIRTS (PACK 4)

1 BOOTS (PAIR) (ISSUE NLT 01 MAY)

JCLC ____________EQUIPMENT LIST / INSPECTION CHECKLIST

CADET ___________________ DATE OF INSPECTION: __________________