Summer Camp Nomination / Registration Form - US Air Force Youth Programs

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US Air Force Youth Programs
Summer Camp Nomination / Registration Form
Privacy Act of 1974
Authority: Title 10, United States Code, Section 8013
Principal Purposes: To obtain youth and family program eligibility and background information for proper
assignment of the individual into activities and workshops; to contact participant’s parents/guardians in the event of
an accident or illness; obtain sponsor consent for access to emergency medical care.
Routine Uses: To provide information to medical personnel in the absence of a parent; to notify the parents in case
of emergency, to contact the youth’s parent’s/guardian relative to the youth’s participation in programs.
Disclosure: Disclosure of requested information is mandatory.
*This applies to all pages in the Air Force Youth Programs Camp registration package.
Camp Choice: 2
Camp Choice: 3
Camp Choice:
LIVE GREEN: Applications must be submitted in original digital format and digitally signed.
First Name:
Last Name:
Age as 31 May:
Adult Shirt Size:
Grade this Fall:
Cumulative GPA:
Sponsor’s Status (Check One):
AD assigned to AF / AF-led JB
Retired Air Force DOD Civilian (APF/NAF)
Air Force Reserve Air National Guard
Parent E-Mail Address for all correspondence:
Has your sponsor been deployed
within the last 6 months?:
Parent/Guardian Information
Additional Emergency Contact
Contact #:
Contact #
Contact Name/Relation:
Phone #:
I hereby authorize my child to receive emergency medical treatment whenever it is deemed necessary at any U.S.
Military Facility or any other medical facility when a U.S. Military Medical Facility is not available.
Health Insurance:
Policy Number:
1. List any medical conditions, allergies, and medications which may require camp staff awareness. All
medications must be prescribed by a physician and have written directions for administration (number of times
per day, amount of medication to be administered). Provide the instructions below to supplement those
indicated on the prescription bottle. Indicate any medications which require special storage:
2. List special dietary or physical accommodation requirements:
Additional Notes:
I understand and to the best of my knowledge all of the information stated herein this document is true and
Signature of Parent/Guardian
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