Your ADDRESS, STATE.ZIP CODE TODAYS DATE015 YOUR FULL NAME CITY WHERE YOU LIVE PARENTS PRINTED NAME PARENT SIGNATURE Your printed name Your ADDRESS, STATE.ZIP CODE TEXAS TODAYS DATE 016 Your SIGNATURE Your ADDRESS STATE, ZIP CODE LEAVE BLANK LEAVE BLANK

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

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

PRINT RELATIVE/FRIEND NEIGHBOR PHONE NUMBER 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 SIGNATUREPARENT SIGNATURE

PHYSICIAN STATEMENT OF MEDICAL CLEARANCE, is medically cleared to participate in JCLC during (Print Cadet’s Name) the period of / / 2016 to / /2016, 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. No signature is needed below by doctor, unless a physical is not attached. ____________ Print Type/ Name of DoctorAddress/Office/Clinic Signature of Doctor DatePhone

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

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

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