Student /Instructor  Registration Form :      PRIVATE  PILOT GROUND SCHOOL   --                                                                                                                                                     

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 ___________________________________________________________________

                                                             Medical Release Form

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

RTSC1@JUNO.COM

(703-549-7722)1