Joint IAWG / NEWG Encampment 2023

Joint IAWG / NEWG Encampment 2023

Page 1 | Applicant Info
Name
N/A

Required First Required Middle Required Last
Email *
N/A
CAPID *
N/A
CAP Grade *
N/A
Squadron Charter Number *
N/A
Date of Birth *
N/A

dd-MMM-yyyy
Religious Preference
N/A
Grade In School
N/A
Shirt Size *
N/A

Page 2 | Application
Application Type *
N/A

Basic Cadet
Cadet Staff (APPLICATIONS ARE CLOSED)
Senior Staff

Page 3 | Emergency Contact
Emergency Contact #1
Name
N/A

Required First Required Last
Phone *
N/A
Email *
N/A
Relationship *
N/A
Emergency Contact #2
Name
N/A

Required First Required Last
Phone *
N/A
Email *
N/A
Relationship *
N/A

	True
None of the conditions listed below apply to me

	Date
Tetanus Booster
Hepatitus Vaccine
Pneumonia Vaccine
Varicella Immunization/Chickenpos
Influenza Vaccine

Page 7 | CAPF 161 Emergency Information
Family Physician
Name
N/A

First Last
Phone
N/A
Address
N/A

Street Address
Address Line 2 City State/Region/Province
Postal / Zip Code

Country
Primary Insurance Information
Medical Insurance Company
N/A
Policy Number
N/A
Group Code/Number
N/A

Page 8 | CAPF 163 OTC Medications
PERMISSION FOR PROVISION OF MINOR CADET OVER-THE-COUNTER MEDICATION

This form may not be usable in some states due to statutes concerning who can administer medications and administration conditions. Wings with such restrictions will publish appropriate additional guidance in a supplement to CAPR 160-1.
Over-The Counter/Non-Prescription Medications

The following over-the counter medications may be administered according to package directions by CAP senior members. Notify us below of any medications not approved.
- Acetaminophen (Tylenol) for fever or pain
- Ibuprofen (Advil, Motrin) for fever or pain
- Bacitracin or Neosporin antibiotic ointment to prevent infection
- Hydrocortisone anti-inflammatory rash cream
- Calamine/Caladryl for poison ivy itch relief
- Antifungal creams and sprays for treatment of fungal rashes
- Visine eye drops for dry, irritated eye relief
- Op-Con A eye drops for allergic conjunctivitis
- Benadryl liquid/tabs for allergic reactions
- Claritin antihistamine for seasonal allergies
- Robitussin products for relief of cough and cold symptoms
- Delsym to suppress cough
- Tums or Maalox for relief of stomach upset
Allergies or OTC drugs not apporoved.
N/A

My child/ward has the following allergies or reactions to over-the-counter medications (list type of reaction):
Consent For Minor Cadet To Receive Over-The-Counter Medications

My signature below evidences my consent for CAP senior members to provide over-the-
counter non-prescription medications (such as those listed above) to my child/ward if indicated in the reasonable judgment of such senior members. I understand that I will be informed if any
such medications are administered.
Date
N/A

dd-MMM-yyyy
Signature
N/A

E-Signature Field
Clear
Any aditional medical information we should know.
N/A

Page 9 | Release Agreement - Applicant
KNOW ALL MEN BY THESE PRESENTS that I am submitting my application for Civil Air Patrol Special Activities or Encampments, and I hereby volunteer entirely upon my own initiative, risk, and responsibility for an assignment to participate in this activity of encampment at the first available opportunity and with full knowledge that such activity may include:

1. Traveling by land, sea, or air in US military, commercial, or privately owned vehicles from regular place or residence to the site of the activity or encampment, travel incident to the activity or encampment, and subsequent return to place of residence.
2. Participation in aeronautical activities as a passenger or student trainee in US military, commercial, or privately owned aircraft.
3. Living for a period of one week or more on diminished rations and minimal shelter simulating actual survival conditions.
4. Being quartered and/or subsisting away from regular or normal place of residence for an extended period of time.
5. Remaining with the cadet group I am assigned to at all times during the activity or encampment.
6. Acting as a spokesman for Civil Air Patrol, rendering reports on the activity or encampment.
7. Refraining from argumentative discussions concerning governmental policies.
8. Allowing use of photos/videos from the event to be posted to social media and used by Public Affairs Officers and Commanders of Civil Air Patrol.

In consideration of the permission extended to me by the Civil Air Patrol/United States of America through its officers and agents to participate in said activity/encampment or activities/encampments, I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Civil Air Patrol, Inc./United States of America, and all its officers, agents, and employees acting official or otherwise, from any and all claims, demands, actions, or causes of action, on account of my death or on account of any injury to me or my property which may occur as a result of the negligence of the Civil Air Patrol/United States of America, its agents or employees during said activity/encampment or activities/encampments or continuances thereof, as well as all ground and flight operations incident thereto.
Date *
N/A

dd-MMM-yyyy
Name
N/A

Required First Required Middle Required Last
Signature *
N/A

E-Signature Field
Clear

Page 10 | Release Agreement - Parent/Guardian
KNOW ALL MEN BY THESE PRESENTS: WHEREBY my child has applied for the activity or encampment referred to above, In consideration of the permission extended to my child by the Civil Air Patrol/United States of America, Camp Dodge, or additional supporting agencies, through its officers and agents to participate in said activity/encampment or activities/encampments, I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Civil Air Patrol, Inc./United States of America, Camp Dodge, or additional supporting agencies, and all its officers, agents and employees acting official or otherwise, from any and all claims, demands, actions or causes of action, on account of the death or on account of any injury to my child which may occur as a result of the negligence of the Civil Air Patrol/United States of America, Camp Dodge, or additional supporting agencies, its agents or employees during said activity/encampment or activities/encampments or continuances thereof, as well as all ground and flight operations incident thereto. In addition, by my signature below, I certify the applicant:

1. Is my minor child or ward.
2. Has no history or injury or disease which might be affected by this activity except those previously noted in the Medical Information section of this form.
3. Will follow all rules, regulations, and directives as established by the Civil Air Patrol, Inc., activity project officer or encampment commander, or other staff members. If not following the above mentioned rules, regulations, and directives he/she may be sent home at the discretion of the project officer, encampment commander or activity directory at my expense.

However, in case of injury, disease or other illness, permission is hereby granted to treat the applicant as required, and if the applicant is released from the activity before recovery from said injury, disease, or illness, further treatment will be provided by myself.
Date
N/A

dd-MMM-yyyy
Witness for Father's Signature
N/A

E-Signature Field
Clear
Father or Legal Guardian
N/A

E-Signature Field
Clear
Witness for Mother's Signature
N/A

E-Signature Field
Clear
Mother or Legal Guardian
N/A

E-Signature Field
Clear

Page 7 | Fees & Payment
Application for CEAP funds
N/A

If you are a first time encampment participant, be sure to apply for CEAP funds. YOU MUST ALSO CLICK ON THE ONLINE PAYMENT AREA TO FINISH YOUR APPLICATION.
Online Payment/Receipt System
N/A

You MUST go here to finalize your application for encampment.

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	1st Choice	2nd Choice	3rd Choice
Cadet Commander
Deputy Cadet Commander
First Sergeant
Flight Commander
Flight Sergeant
Public Affairs Officer
Logistics Officer
Admin Officer

	1st Choice	2nd Choice	3rd Choice
Commander
Commandant for Cadets
Deputy Commander for Support
Safety Officer
Chaplain
Chief/Senior Training Officer
Training Officer
Kitchen Officer
Public Affairs Officer
Logistics Officer
Finance Officer
Admin Officer

	No	Yes
Decreased vision, glaucoma, contacts
Ear infections, perforation
Difficulty equalizing ears
Hearing loss, hearing aid
Allergies, nasal stuffiness
Anaphylaxis, serious allergic reaction
Asthma, emphysema (COPD)
Ever use an inhaler
Short of Breath with activity
Heart Attack, chest pain, angina
Heart murmur, heart problems
Congestive heart failure
Irregular or rapid heartbeat
High or low blood pressure
Stomach trouble, ulcers
Hepatitis or liver problems
Diarrhea, constipation
Hernia or rupture
Kidney disease or stones
Prostate problems (men)
Frequent urination
Menstrual cramps (women)
Broken bone, joint problems
Chronic or recurring injuries
Activity, mobility restrictions
Use of cane, walker, wheelchair
Back or neck pain or injury
Migraine or severe headaches
Dizziness or fainting spells
Head injury, unconsciousness
Epilepsy or seizure
Stroke, paralysis
Thyroid problems (low or high)
Diabetes, high or low blood sugars
Cancer, leukemia
Blood disease, hemophilia
Motion sickness
Special diet, food allergies
Current bedwetting problems
ADD (Attention Deficit Disorder)
Mental illness (bipolar, other)
Depression, anxiety, suicidal
Admission to the hospital
Other chronic medical illnesses
Sleep disorder, sleep apnea
Serious Injury

	Name of Medication	Tablet Strength	Time Taken/Day	Reason for Medication	Special Dosing or Storing Instructions
1.
2.
3.
4.

Joint IAWG / NEWG Encampment 2023

Page 1 | Applicant Info

Page 2 | Application

Page 4 | Cadet Staff Application

Page 5 | Senior Staff Application

Page 3 | Emergency Contact

Emergency Contact #1

Emergency Contact #2

Page 6 | CAPF 160 Health History

Page 7 | CAPF 161 Emergency Information

Family Physician

Primary Insurance Information

Page 8 | CAPF 163 OTC Medications

Page 9 | Release Agreement - Applicant

Page 10 | Release Agreement - Parent/Guardian

Page 7 | Fees & Payment

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