YOUR FULL NAME Your ADDRESS, STATE.ZIP CODE TEXASTODAYS DATE015CITY WHERE YOU LIVE Your signature PARENTS PRINTED NAME PARENT SIGNATURE Your printed name Your ADDRESS, STATE.ZIP CODE

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

PRINT YOUR FULL LAST NAME, FIRST NAME, MIDDLE INITIAL PRINT PARENTS FULL NAME 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 DOCTOR’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 / / 2015 to / /2015, 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, in lieu of completing this form.) ____________ 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