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CADET ACTIVITY MEDICAL INFORMATION FORM
All activity participants must complete this form in its entirety. Indicate NONE or NO where applicable. Failure to disclose all
known medical conditions is cause for dismissal from the activity. Attach a current copy of the member’s insurance card to the application
submission. Parent/guardian of cadets age 17 and under must complete this form.
PART I – MEMBER & EMERGENCY CONTACT INFORMATION
PART II – INSURANCE INFORMATION
PART III – MEDICATION INFORMATION & AUTHORIZED NON-PRESCRIPTION MEDICATION
List ALL prescription, over-the-counter (OTC), and herbal medications taken. Include medication name, dosage, and time to be given. ALL medications MUST be
in the original container. DO NOT bring any medications in daily pill packs. For cadets 17 and under, indicate which over-the-counter medicines, their generics, or a similar
product if necessary or deemed appropriate by the health services officer may be given. No product endorsement is implied. INITIAL next to each OTC medication authorized.
Permission for Administration of Non-Prescription Medications
. Non-prescription medications may be given to minor cadets as needed and
according to package directions by CAP senior members, and only if permission is given in writing by the cadet’s parent or guardian. I hereby grant
permission to the Civil Air Patrol and the Health Services Officers of this activity to administer the medications indicated below to my cadet/child
during this activity after consultation and as directed by myself (initial next to each medication authorized).
____ Acetaminophen (Tylenol®)
PART IV – MEDICAL HISTORY & INFORMATION
Has the member had, or currently have, any of the following? Circle Y for yes, N for no. If yes, explain in the remarks section with date and physicians consulted.
Y | N Frequent Headaches
Y | N Eye Trouble except glasses
Y | N Other (List in Remarks)
Y | N The member has been or is now waived from physical training by a doctor. Y | N Is there anything else not specifical y listed that should be known? REMARKS
. Describe all medications being taken, medical ailments, recent
. List any allergies to medications, food, insects, etc.
accidents and injuries, other accidents and injuries, and other conditions.
DIETARY RESTRICTIONS. Medical, religious, vegetarian, etc.
PART V – MEMBER OR PARENT/GUARDIAN CERTIFICATION & CONSENT
I hereby grant permission for the activity Health Services Officer to share this information with CAP Senior Staff members and any health care providers as necessary to ensure appropriate healthcare services are provided for my cadet/child (or myself if age 18 or over). I ( DO ) (DO NOT) (circle DO or DO NOT – line through other)
authorize the health services staff to collect and safeguard my minor cadet’s medication for the duration of the activity. PARENT/GUARDIAN NAME (OR MEMBER OVER 18) (TYPED)
PARENT/GUARDIAN SIGNATURE (OR MEMBER OVER 18)
FLWG Form 504, 26 Oct 11
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