USNA 1110/97 (2-19)
Adobe LC ES4
OMB 0703-0036
PRIVACY ACT STATEMENT:
AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 6954, Midshipmen: number; 10 U.S.C. 6956, Midshipmen: nomination and selection
to fill vacancies; 10 U.S.C 2192, Improvement of education in technical fields: general authority regarding education in science, mathematics, and
engineering; E.O. 9397 (SSN), as amended; DoDI 1322.22, Service Academies; and SORN N01531-1.
PURPOSE: To collect necessary information and permission to treat participants needing medical attention while attending a U.S. Naval Academy
student program.
ROUTINE USE(S): Used by admissions to obtain parent/legal guardian consent for minor's participation in recreational and physical activities and
consent for medical treatment of a minor if needed while attending a U.S. Naval Academy student program.
DISCLOSURE: Voluntary; however, failure to provide the requested information, failure to consent to treatment, or failure to provide/obtain
health insurance will result in participants dismissal from the student program.
UNITED STATES NAVAL ACADEMY STRATEGIC OUTREACH MEDICAL CONSENT STUDENT FORM
3. LAST NAME:
2. MIDDLE NAME:
1. FIRST NAME:
5. APARTMENT, SUITE, UNIT, BUILDING, FLOOR, ETC.:
4. HOME ADDRESS (Street address, P.O. box):
6. CITY:
10. DATE OF BIRTH (Example: 9/28/2017):
7. STATE/PROVINCE: 8. ZIP/POSTAL:
15. DIETARY RESTIRICTIONS. If you have any type of dietary restriction, please describe it
below. Meal service is family style, so USNA may not be able to accommodate all restrictions.
12. PHONE NUMBER
(Example: 301-555-1234):
9. COUNTRY:
11. GENDER:
MALE: FEMALE:
13. TYPE:
CELL: HOME:
14. Do you child/legal dependent have any type of
dietary restriction, including but not limited to:
vegetarian, vegan, gluten intolerance?
YES: NO:
SECTION 2: CONSENT TO TREATMENT OF A MINOR
By signing below, I do hereby consent to any emergency x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care
which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the
provisions of the Medical Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care
being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis,
treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable; and neither said agent or any
organization involved assumes any financial responsibility for exercising this action.
SPECIAL NOTICE: Health insurance is a requirement to attend Naval Academy Student Programs. If a participant does not have health insurance, a
short term policy will need to be purchased for the duration of the program. Forms will not be accepted without valid insurance information and parent
consent signature.
17. HEALTH INSURANCE POLICY NUMBER (Tricare Benefits Number):
16. HEALTH INSURANCE CARRIER:
18. PARENT/GUARDIAN NAME:
19. PARENT/GUARDIAN SIGNATURE:
SECTION 1: PARTICIPANT INFORMATION
AGENCY DISCLOSURE NOTICE:
The public reporting burden for this collection of information, OMB 0703-0036, is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil.
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a current valid OMB control number.
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