1. YOUR FULL NAME TODAYS DATE 015 Your printed name PARENTS PRINTED NAME
CITY WHERE YOU LIVE
TEXAS
TODAYS DATE
TODAYS DATE
015
019
Your printed name
PARENTS PRINTED NAME
Your SIGNATURE
PARENT SIGNATURE
Your ADDRESS
STATE, ZIP CODE
Your ADDRESS,
STATE.ZIP CODE
Your ADDRESS, STATE.ZIP CODE
LEAVE BLANK LEAVE BLANK LEAVE BLANK LEAVE BLANK

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

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

4. READ STATEMENT BELOW AND INITIAL
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. , is medically cleared to participate in JCLC during
PHYSICIAN STATEMENT OF MEDICAL CLEARANCE
, is medically cleared to participate in JCLC during
(Print Cadet’s Name)
the period of 05/30 / to 06 /06/2019, for the (YOUR HIGH SCHOOL NAME) 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. No signature is needed below by doctor, unless a physical is not attached.
____________
Print Type/ Name of Doctor Address/Office/Clinic
Signature of Doctor Date Phone

6. TODAYS DATE CADET’S SIGNATURE PARENT OR GAURDIAN SIGNATURE
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. SIGN PARENTS FULL NAME 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

8. PRINT THEIR ADDRESS PRINT THEIR CITY
PRINT YOUR LAST NAME, FIRST NAME AND MIDDLE INITIAL (IF ANY)
LEAVE BLANK
PRINT YOUR FULL ADDRESS
PRINT YOUR CITY
TEXAS
PRINT YOUR ZIP CODE
PRINT YOUR SCHOOL
PRINT YOUR LET LEVEL
LEAVE BLANK
LEAVE BLANK
LEAVE BLANK
LEAVE BLANK
LEAVE BLANK
PRINT NAME AND RELATIONSHIP (FOR EXAMPLE:RELATIVE/FRIEND/NEIGHBOR)
PRINT THEIR ADDRESS PRINT THEIR CITY
TEXAS OR STATE (IF OUT OF STATE) ZIP CODE
LEAVE THIS LINE AND BELOW BLANK LEAVE BLANK