Course Registration Form

Course Name: START DATE_________

Location:

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Participant Information (Type or Print)

LAST Name _______________________________FIRST Name____________________________

Street Address: ________________________________________________________

City:____________________ State:___________________ Zip Code:________________

Social Security No. LAST FOUR DIGITS              ___________

Date of Birth   Yr(            )Mo(       ) Day(        ) Sex ( Circle One)    M       F

Home Phone:____________________   E Mail _____________________________________

Father's Name ___________________________________________________________

Home Phone:__________________ Work Phone:___________________ _Cell Phone__________________

Mother's Name ___________________________________________________________

Home Phone:____________________ Work Phone:_______________________ Cell Phone _______________

Your height_________ (inches) and Weight________ (Lbs)

Medical Release Form

I hereby authorize any physican 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 on the application - applicants taking psychotropic medicines WITHIN THE LAST SIX MONTHS will not be accepted.

Your Signature:______________________________________________ Date:______________

Relationship to the student:___________________________________________

Remarks:_________________________________________________________________________________

Are you: NSCC____ YM____ NJROTC____ AFJROTC____ ARJROTC____ BSA____ CAP_____
 OTHER Specify___________ How did you learn about the program?_________________________
 
 
Do you have Health and Accident insurance? YES____ NO____
Send a copy of your insurance card with your Registration Form.

RETURN THE COMPLETED FORM AND FEES TO:
Judge Robert T. S. Colby
Director
Post Office Box 1945

Alexandria, Virginia

E-Mail: RTSC1@JUNO.COM