USNA 1110/97 (1-18)
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. If you have any type of dietary restriction, please describe it here. Note that our meal service
is family style, so we 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
16. 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 USNA Student Programs. If you do not have health insurance, you need to purchase a
short term policy for the duration of your program and sign the forms when you have that information available.
18. HEALTH INSURANCE POLICY NUMBER:
17. HEALTH INSURANCE CARRIER:
19. PARENT/GAURDIAN NAME:
20. PARENT/GUARDIAN SIGNATURE:
SECTION 1: PARTICIPANT INFORMATION
AGENCY DISCLOSURE NOTICE:
The public reporting burden for this collection of information is estimated to average .25 hours, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of
Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09,
Alexandria, VA 22350-3100 (OMB (0703-0036).
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.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS
Responses should be sent to: United States Naval Academy, Office of Admissions, 52 King George St., Annapolis, MD 21402
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