YOUR FULL NAME

1
YOUR FULL NAME
TEXAS
TODAYS DATE
014
CITY WHERE YOU LIVE
PARENTS PRINTED NAME
Your printed name
Your signature
PARENT SIGNATURE
Your ADDRESS, STATE.ZIP CODE
Your ADDRESS, STATE.ZIP CODE
2
YOUR FULL NAME
RHS, JCLC, TX
PRINT THE WORDS NO EXCEPTIONS
CIRCLE ONE (LIST MEDICATION, IF ANY) CIRCLE ONE
(LIST MEDICATION, IF ANY)
YOUR SIGNATURE
YOUR FULL NAME
PRINT PARENTS FULL NAME
YOUR FULL NAME
PARENTS FULL NAME (CONT)
PARENTS SIGNATURE
PRINT PARENTS FULL NAME
3
PRINT YOUR FULL LAST NAME, FIRST NAME, MIDDLE
INITIAL
PRINT THE NAME OF YOUR HIGH SCHOOL
PRINT YOUR PARENT/GAURDIAN FULL NAME AND ADDRESS
PRINT YOUR PARENT/GAURDIAN TELEPHONE NUMBER
PRINT YOUR DOCTORS FULL NAME AND ADDRESS (IF
NONE WRITE NONE)
PRINT YOUR DOCTORS TELEPHONE NUMBER
PRINT YOUR DOCTORS FULL NAME AND ADDRESS (IF
NONE WRITE NONE)
PRINT YOUR DENTISTS TELEPHONE NUMBER
PRINT PARENTS FULL NAME
PRINT RELATIVE/FRIEND/NEIGHBOR/ FULL NAME AND
ADDRESS
4
PRINT RELATIVE/FRIEND NEIGHBOR PHONE NUMBER
READ STATEMENT BELOW AND INITIAL
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 SIGNATURE
PARENT SIGNATURE
5
PHYSICIAN STATEMENT OF MEDICAL
CLEARANCE             , is medically cleared
to participate in JCLC during
(Print Cadets Name)   the period of /
/ 2014 to / /2014, 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 Cadets 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 Doctor Address/Office/Clinic    
Signature of Doctor
Date Phone
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TODAYS DATE
CADETS BIRTH DATE
PRINT CADETS FULL NAME
PRINT CADETS ZIP CODE
PRINT CADETS ADDRESS
PRINT CADETS CITY
CADETS SIGNATURE
PARENT OR GAURDIAN SIGNATURE
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PRINT DISEASE/CONDITION
PRINT PARENT INITIALS IF NO DISEASE/CONDITION
PRINT MEDICATION
PRINT PARENT INITIALS IF NO MEDICATION
PRINT MEDICATION OR ALLERGY
PRINT PARENT INITIALS IF NO MEDICATION OR ALLERGY
PRINT PARENT INITIALS IF NO DISEASE/CONDITION
PRINT CADET FULL NAME
SIGN CADET FULL NAME
TODAYS DATE
DOCTORS PHONE NUMBER
PRINT DOCTORS NAME
SIGN PARENTS FULL NAME
TODAYS DATE
PRINT PARENT FULL NAME
TODAYS DATE
EMERGENCY PHONE NUMBER
PRINT DOCTORS NAME
DOCTORS PHONE NUMBER
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