National Aviation Education and Training Center Course Registration Form

Course Name:

Start Date:

Locations:

Participant Information (Type or Print)

Full Name ___________________________________________________________

Social Security Number:________________________________________________

Street Address: ________________________________________________________
_____________________________________________________________________

City:____________________ State:___________________ Zip Code:________________

Date of Birth:_______________________ (Format: YR/MO/DAY) Sex:____________

Home Phone:____________________

Father's Name ___________________________________________________________

Home Phone:____________________ Work Phone:_______________________

Mother's Name ___________________________________________________________

Home Phone:____________________ Work Phone:_______________________

Medical Release Form

I hereby authorize any physican who cares for my child to administer any treatment
and perform such procedures as may be advisable or necessary.

I further certify that my child has no allergies and is in good physical and emotional health,
except as stated on the application - applicants taking psychotropic medicines will not
be accepted.

Your Signature:______________________________________________ Date:______________

Relationship to the student:___________________________________________

Remarks:_________________________________________________________________________________

Are you:  NSCC____  YM____  NJROTC____  AFJROTC____  ARJROTC____  BSA____  OTHER____


Do you have Health and Accident insurance?   YES____    NO____
Send a copy of your insurance card with your Registration Form.
RETURN THIS COMPLETED FORM AND MAKE CHECKS PAYABLE TO:
Director of Aviation Training
Naval Sea Cadet Corps
2300 Wilson Blvd
Arlington, Virginia 22101-3308

*** Questions? Call NSCC Headquarters at (703) 243-6910 ***
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