YOUR FULL NAME

1. YOUR FULL NAME CITY WHERE YOU LIVE TEXAS TODAYS DATE 014 Your printed name PARENTS PRINTED NAME Your signature PARENT SIGNATURE Your ADDRESS, STATE.ZIP CODE Your ADDRESS, STATE.ZIP CODE

2. YOUR FULL NAME RHS, JCLC, TX PRINT THE WORDS “ NO EXCEPTIONS” CIRCLE ONE (LIST MEDICATION, IF ANY) CIRCLE ONE (LIST MEDICATION, IF ANY) YOUR SIGNATURE YOUR FULL NAME PRINT PARENTS FULL NAME YOUR FULL NAME PARENTS FULL NAME (CON’T) PARENTS SIGNATURE PRINT PARENTS FULL NAME

3. PRINT YOUR FULL LAST NAME, FIRST NAME, MIDDLE INITIAL PRINT THE NAME OF YOUR HIGH SCHOOL PRINT YOUR PARENT/GAURDIAN FULL NAME AND ADDRESS PRINT YOUR PARENT/GAURDIAN TELEPHONE NUMBER PRINT YOUR DOCTOR’S FULL NAME AND ADDRESS (IF NONE WRITE NONE) PRINT YOUR DOCTOR’S TELEPHONE NUMBER PRINT YOUR DOCTOR’S FULL NAME AND ADDRESS (IF NONE WRITE NONE) PRINT YOUR DENTIST’S TELEPHONE NUMBER PRINT PARENTS FULL NAME PRINT RELATIVE/FRIEND/NEIGHBOR/ FULL NAME AND ADDRESS

4. PRINT RELATIVE/FRIEND NEIGHBOR PHONE NUMBER READ STATEMENT BELOW AND INITIAL READ STATEMENT BELOW AND INITIAL PRINT THE LETTERS “ N/A” (OR PRINT CONDITION , IF ANY) PRINT THE LETTERS “ N/A” (OR PRINT MEDICATION , IF ANY) PRINT THE LETTERS “ N/A” (OR PRINT MEDICINES STUDENT IS ALLERGIC TO, IF ANY) READ STATEMENT AND CIRCLE ONE CADET SIGNATURE PARENT SIGNATURE

5. PHYSICIAN STATEMENT OF MEDICAL CLEARANCE , is medically cleared to participate in JCLC during (Print Cadet’s Name) the period of / / 2014 to / /2014, for the Richland High School JROTC. (MONTH/DAY) (MONTH/DAY) (Name of School) The patient is not precluded physical activity due to _______________________________ (Condition/ medication/allergies) _____________________________________________. To the best of my knowledge,______________________________________________ Print Cadet’s Name Is (other than stated above) in good physical condition. Participation in JCLC, in my opinion, will not have an adverse effect on his/her health and well-being. (If cadet has taken a recent physical, attach physical with clearance, in lieu of completing this form.) ____________ Print Type/ Name of Doctor Address/Office/Clinic Signature of Doctor Date Phone

6. TODAYS DATE CADETS BIRTH DATE PRINT CADETS FULL NAME PRINT CADET’S ZIP CODE PRINT CADET’S ADDRESS PRINT CADET’S CITY CADET’S SIGNATURE PARENT OR GAURDIAN SIGNATURE

7. PRINT DISEASE/CONDITION PRINT PARENT INITIALS IF NO DISEASE/CONDITION PRINT MEDICATION PRINT PARENT INITIALS IF NO MEDICATION PRINT MEDICATION OR ALLERGY PRINT PARENT INITIALS IF NO MEDICATION OR ALLERGY PRINT PARENT INITIALS IF NO DISEASE/CONDITION PRINT CADET FULL NAME SIGN CADET FULL NAME TODAYS DATE DOCTORS PHONE NUMBER PRINT DOCTORS NAME SIGN PARENTS FULL NAME TODAYS DATE PRINT PARENT FULL NAME TODAYS DATE EMERGENCY PHONE NUMBER PRINT DOCTORS NAME DOCTORS PHONE NUMBER