Start Date: ____________
1. Last Name ____________________ _First Name____________ Middle Initial_______
2. Street Address: ________________________________________________________
3. City:____________________ State:___________________ Zip Code:_____________
4. Social Security No. LAST FOUR DIGITS ___________
5. Date of Birth Yr( ) Mo ( ) Day ( ) Sex ( Circle One) M F
6. Home Phone:____________________ E Mail _____________________________________
7. Father's Name ___________________________________________________________
8. Home Phone: ____________________ Work Phone: ___________________ _Cell Phone ____________________
9. Mother's Name ___________________________________________________________
10. Home Phone:____________________ Work Phone:_______________________ Cell Phone _______________
11. For Shirt Size -- Circle (S) (M) (L) (XL) (2XL) (3XL)
12. Ratings/hours flown ___________________________________________________________________
I hereby authorize any physician who cares for my child to administer any treatment and perform such procedures as may be advisable or necessary. I further certify that my child has no allergies and is in good physical and emotional health, except as stated below on this application. Applicants taking MOOD CHANGING and/or PSYCHOTROPIC medicines WITHIN THE LAST SIX MONTHS will NOT be accepted.
Remarks and medications being taken: _________________________________________
Your Signature:______________________________________________ Date:______________
Relationship to the student:_________________ Do you have health and accident insurance ? YES______ NO_______
Are you: NSCC___ YM___ NJROTC___ AFJROTC___ ARJROTC___ BSA___ CAP____ OTHER ___________ Send a copy of your insurance card with your Registration Form.
RETURN THE COMPLETED FORM
AND FEES TO:
JUDGE
ROBERT T. S. COLBY
2034
Eisenhower Ave Rm 145A
ALEXANDRIA, VA 22314