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National Défense
Defence nationale |
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PROTECTED A (when completed) – PROTÉGÉ
A (une fois rempli) |
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| APPLICATION
AND APPROVAL – CADET ACTIVITIES (EMPLOYMENT – COURSE – EXCHANGE)
DEMANDE DE
PARTICIPATION ET APPROBATION – ACTIVITIES DE CADETS (EMPLOI – COURS
– ECHANGE)
PART 1 – APPLICATION (To be completed by cadet and parent or guardian)
PARTIE 1 – DEMANDE (A
remplir par le cadet et le parent ou tuteur) |
SECTION “A” – PERSONAL DATA – RENSEIGNEMENTS PERSONNELS |
| CADET CORPS/SQUADRON
CORPS/ESCADRON
DE CADETS |
NO. & NAME - Nº
ET NOM
532 MAITLAND
RC(AIR)CS |
LOCALITY (CITY) -
LOCALITE (VILLE)
GODERICH |
| IDENTIFICATION OF
CADET
IDENTIFICATION
DU CADET |
RANK - GRADE
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SURNAME - NOM
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FIRST NAME - PRENOMS
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Male
Female |
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HOME ADDRESS
ADRESSE DOMICILIAIRE |
ADDRESS - ADRESSE
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CITY - VILLE
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PROV.
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POSTAL CODE POSTAL
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| TELEPHONE NO.
Nº DE TELEPHONE |
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-
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PROVINCIAL HOSIPTAL
INSURANCE NO.
Nº D'ASSURNACE-MALADIE
DU REGIME PROVINCIAL |
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AGE-AGE
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DATE OF BIRTH - DATE
DE NAISSANCE |
| Day - Jour
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Month - Mois
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Year -Annee
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| LANGUAGES
LANGUES |
PRIMARY - MATERNELLE
OTHERS - AUTRES |
RELIGION
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DATE OF REGISTRATION
- DATE D'INSCRIPTION AUX CADETS
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Day - Jour
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Month - Mois
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Year - Annee
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SECTION “B” – LHQ TRAINING / COURSES
/ EXCHANGES ATTENDED OR PREVIOUS EMPLOYMENT
INSTRUCTION A L'UNITE / COURS SUIVIS
/ ECHANGES OU EMPLOIS ANTERIEURS |
| LAST LHQ TRAINING
LEVEL COMPLETED - DERNIER NIVEAU D'INSTRUCTION COMPLETE A L'UNITE
1.
IF OTHER UNIT:
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YEAR - ANNEE
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LEVEL - NIVEAU
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| COURSES/EXCHANGES/EMPLOYMENT
- COURS/ECHANGES/EMPLOIS
2.
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YEAR - ANNEES
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CSTC OR CONTRY OF
EXCHANGE - CIEC OU PAYS D'ECHANGE
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4.
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| 5.
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| SECTION "C" - CADET ACTIVITY(IES)
REQUESTED - ACTIVITE(S) DE CADETS DEMANDEE(S) |
| CHOICES - CHOIX
1. |
EMPLOYMENT/COURSE/EXCHANGE
- EMPLOI/COURS/ECHANGE
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CSTC OR COUNTRY OF
EXCHANGE - CIEC OU PAYS D'ECHANGE
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| SECTION "D" - DECLARATION
OF PARENT OR GUARDIAN - DECLARATION DU PARENT OU TUTEUR |
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Yes - Oui |
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No - Non |
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| 1. I give my consent to my son/daughter/ward
to attend the requested
cadet activity(ies) |
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1. Je consens a ce
que mon fils/ma fille/mon ou ma pupille particpe
a l'(aux) activite(s) de cadets demandee(s) |
| 2. Authority is granted for my son/daughter/ward
to travel on commercial
or military aircraft, ships and vehicles
as deemed necessary by the
service. |
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2. Je consens a ce
que mon fils/ma fille/mon ou ma pupille voyage
par avion, naivre ou autre vhicule commercial
ou militaire suivant
les exigences du service |
| 3. Permission is granted
to issue weekend pass and/or evening pass. |
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3. Les permissions
de fin de semaine et/ou de soiree sont autorisees. |
| 4. I understand that
if I request that my son/daughter/ward be returned
home prior to completion of the cadet actvity(ies),
I may be liable for
transportation cost. |
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4. Il est entendu
que si je demande que mon fils/ma fille/mon ou ma
pupille soit retourne(e) a la maison avant
la fin de l'(des) activite(s)
de cadets je peux etre tenu responsable
des frais de transport. |
| 5. Is there a court
decree or judgement or seperation agreement in
existence, the terms of which award you
the custody of your son/
daughter/ward and/or award visiting rights
or restrict access to your
son/daughter/ward by another party? If yes, provide additional
information under separate cover. |
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5. Existe-t-il une
ordonnance ou un jugement d'un tribunal ou un
contrat de separation, stipulant que la
garde de votre fils/fille/
pupille vous est confiee et/ou qui autorise
des droits de visites
ou restreint l'acces a votre fils/fille/pupille
par une autre personne?
Si oui, priere de fournir de plus amples
details par courrier separe. |
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(Signature of Parent/Legal Guardian)
(Signature du parent/tuteur legal) |
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Same address and telephone
as in Section “A” above; or
Meme adresse domiciliaire
et no de telephone identifies dans la Section “A” ci-dessus; ou |
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ADDRESS - ADRESSE
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CITY - VILLE
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PROV.
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POSTAL CODE POSTAL
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TEL - TEL.
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| IF PASSES AUTHORIZED
ON
A RESTRICTED BASIS,
INDICATE:
SI DES PERMISSIONS
SON
ACCORDEES SUR UNE
BASE
RESTREINTE, INDIQUER: |
NAME (Relative, Friend
to be visited) – NOOM (parent ou ami qui sera visite)
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TEL - TEL.
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| ADDRESS - ADRESSE
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CITY – VILLE
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PROV.
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POSTAL CODE POSTAL
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| PARENT/GUARDIAN
Summer Address (if
applicable)
PARENT/TUTEUR
Adresse Durant l’ete
(s’il y a lieu)
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ADDRESS - ADRESSE
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CITY – VILLE
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PROV.
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TEL - TEL.
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| POSTAL CODE POSTAL
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ALTERNATE FAMILY/ADULT
CONTACT(In case of
emergency)
POINT DE CONTACT
SUPPLEMENTAIRE FAMILLE/
ADULTE (En cas d’urgence) |
NAME - NOM
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TEL - TEL.
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| ADDRESS
- ADRESSE
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CITY
– VILLE
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PROV.
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POSTAL
CODE POSTAL
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| CF 51 (12-98) 7530-21-914-9248 |
PROTECTED A (when
completed) – PROTÉGÉ A (une fois rempli) |
Design: Forms Management 993-4050 (-3-99)
Conception: Gestion
de formulas 993-3778 |
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PROTECTED A (when completed) –
PROTÉGÉ A (une fois rempli)
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CADET
CORPS/SQUADRON NO.
Nº DU
CORPS/ESCADRON DE CADETS
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LOCALITY (CITY)
LOCALITE (VILLE)
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PART 2 – MEDICAL INFORMATION
(To be
completed by the parent / guardian)
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PARTIE 2 – RENSEIGNEMENTS MEDICAUX
(A
remplir par le parent ou tuteur)
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SECTION “A” – PERSONAL DATA – RENSEIGNEMENTS PERSONNELS
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FAMILY NAME OF THE
CADET – NOM DU CADET
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GIVEN NAME - PRENOM
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DOB - DDN
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SEX - SEXE
M F
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BLOOD GROUP (if
known)
GROUPE SANGUIN (si
connu)
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PROVINCIAL HOSPITAL
INSURANCE NUMBER (Mandatory)
Nº D’ASSURNACE-MALADIE
DU REGIME PROVINCIAL (Obligatoire)
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SECTION “B” – MEDICAL INFORMATION – RENSEIGNEMENTS MEDICAUX
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1. Your
son/daughter/ward will participate in the following activities
while at the training center or during
the exchange: strenuous
physical activities, drill and marching
on hard surfaces, swimming
and other water sports, running team
sports, outdoor training for
one or more nights in locations remote
from medical facilities.
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Yes
Oui
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No
Non
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1. Votre
fills/fille/pupille participera aux activities suivantes du centre
d’instruction ou durnat l’echange:
activities physiques ardues, exer-
cices militaries et marches sur des
surfaces dures, natation et autres
sports aquatiques, course en equipe,
séance d’entrainement a
l’exterieur Durant une ou plusieurs
nuits dans des endroits eloignes
d’installations medicales.
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2. Does your
son/daughter/ward have a medical condition or problem
requiring access, within 20-30 minutes,
to specialist physician or
general practitioners?
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2. Votre
fils/fille/pupille a-t-il/elle un probleme medical requerant acces
a un medecin generaliste ou specialiste
en mois de 20 a 30
minutes?
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3. If a specialist
physician is required, specify the type.
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3. Si un medecin
specialiste est requis, veuillez preciser la specialite
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4. Is your
son/daughter/ward being treated or managed by a
physician for any of the following:
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a. lung disease, chronic cough, wheezing
or asthma?
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a. maladie
pulmonaire, toux chronique, respiration asthmatique
ou asthme?
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b. heart problems?
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b. troubles
caradiaques?
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c. bed wetting?
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c. incontinence
nocturne?
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d. seizure disorders, fits, convulsions,
epilepsy?
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d. troubles
desordonnes, crises, convulsions, epilepsie?
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e. diabetes?
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e. diabete?
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f.
arthritis or other joint problems?
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f. arthrite ou
autres problems d’articulations?
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g. foot problems that may restrict
activities?
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g. problemes de
pied qui pourraient limiter les activities?
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h. any condition requiring a special
diet?
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h. une condition
exigeant un regime alimentaire special?
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i.
serious allergeries (to bee stings or other insects, or to drugs
such as penicillin)?
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i. allergies graves
(aux piqures d’abeilles ou a d’autres insects,
ou a des medicaments comme la
penicilline)?
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j. any skin conditions that could
restrict activities?
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j. conditions de la
peau qui pourraient restreindre les activities?
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k. any other medical condition not
listed above, especially if
they may limit activities
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k. toute autre
maladie non enumeree ci-haut, surtout si elle peut
restreindre les activities?
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l. dental problems?
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l. problemes
dentaires?
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If you answered yes to any of
the above questions please
Give additional details in paragraph 8.
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Si vous avez repondu oui a l’une des
questions precedents, veuillez donner des details au paragraphe 8.
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5. Is your
son/daughter/ward on any prescribed medication (including allergy serum, ie,
Anakit or EpiPen)?
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Votre fils/fille/pupille prend-il/elle
presentement des medicaments prescripts par un medecin (incluant du serum
d’allergie, c-a-d. “Anakit” ou “EpiPen”)?
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Please
specify, listing the type and dosing strength/intervals
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Veuillez preciser, indiquant le genre,
la dose et les intervalles.
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6. Is your
son/daughter/ward currently undergoing physiotherapy, counseling or therapy
for any reason?
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Votre fils/fille/pupille recoit-il/elle
presentement de la physiotherapie , un service de conseil ou de la therapie
qu’importe la raison?
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Please
identify/specify
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Veuillez identifier/preciser
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7. Has your
son/daughter/ward ever been hospitalized and/or undergone any operation? For
what reason and when:
Votre fils/fille/pupille a-t-il(elle)
deja ete hospitalize(e) et/ou subi une operation chirurgicale? Pour quelle raison et quand:
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8. Is there
anything else that you wish the training center or exchange location medical
staff to be aware of?
(Details on any positive response to a
question in paragraph 4 are needed.)
Y a-t-il d’autre information que le
personnel medical du center d’instruction ou du lieu d’echange doit savoir?
(Chaque
response affirmative aux questions du paragraph 4 requiert plus de details.)
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PROTECTED A (when
completed) – PROTÉGÉ A (une fois rempli)
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PROTECTED A (when completed) –
PROTÉGÉ A (une fois rempli)
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NOTES
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NOTA
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1. This form will
be reviewed by cadet authorities.
Further information from your
family doctor may be required should
you provide any positive responses to the
preceding questions. In order to avoid delays in obtaining such
information by
our medical personnel, you are requested
to sign the release of medical
information statement contained in
section C below.
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1. Ce formulaire
sera examine par les autorites de cadets.
Il pourrait s’averer
necessaire d’obtenir de plus amples
renseignements de votre medecin de
famille si vous avez repondu affirmativement a l’une des
questions
precedents. Pour eviter tout retard dans l’obtention
de ces renseignements
par notre personnel medical, veuillez
signer l’autorisation a communiquer des
renseignements medicaux a la section C
ci-dessous.
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2. Should you have
any concerns respecting your son/daughter/ward’s suitability
to undertake cadet activity(ies), you
are encouraged to discuss these concerns
with your family doctor and the
corps/squadron Commanding Officer.
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2. Vous ete pries
de consulter votre medecin de famille et le commandant du
corps/de l’escadron si vous avez des
inquietudes concernant l’aptitude de
votre fils/fille/pupille a participer a
l’(aux) activite(s) de cadets.
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3. You are strongly
encouraged to have your son/daughter/ward immunized
against tetanus, diphtheria, polio,
measles, mumps and (for female cadets)
rubella. Of particular importance is immunization against tetanus due to
the
possibility if injury in the field
during training. Immunization of your
son/daughter/ward is your complete
responsibility, as are potential difficulties
arising from lack of immunization. Any unimmunized cadet present at a
training
centre or exchange location which is the
site of an outbreak of disease may be
returned home immediately to lessen the
danger of his/her infection.
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3. On vous
encourage fortement a faire vacciner votre fils/fille/pupille contre le
tetanus, la diphterie, la poliomyelite,
la rougeloe, les oreillons et (pour les
cadets de sexe feminine) la
rubeole. L'immunisation contre le
tetanos est tres
importante a cause de la possibilite de
se blesser durant les exercises
exterieurs. Vous etes responsables de l'immunisation de votre
fils.fille/pupille,
ainsi que des complications pouvant
survenir faute d'immunisation. S'il
n'a
pas ete vaccine, un cadet present dans
un centre d'instructions ou un lien
d'echange ou se manifestent les
premiers signes d'une maladie peut etre
renvoye immediatement a la maison pour
reduire les risques d'infection.
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4. Should your
son/daughter/ward develop any medical problem or condition after
completion of this form, you shall
inform the corps/squadron Commanding
Officer who will notify the Regional
Cadet Staff.
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4. Si votre
fils/fille/pupille eprouve un probleme medical apres la soumission de
ce formulaire, vous devez en informer le
commandant du corps/de l'escadron,
qui avisera l'etat-major regional des
cadets.
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SECTION “C” –
CERTIFICATION/AUTHORIZATION – ATTESTATION/AUTORISATION
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1. I certify that
the information above is complete and accurate. I also certify that
my son/daughter/ward is healthly and in
good physical condition with all the
exceptions previously noted.
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1. J'atteste que
les renseignments ci-dessous sont exactes et complets. J'atteste
aussi que mon fils/ma fille/mon ou ma
pupille est en bonne sante et en bonne
condition physique sauf pour les
exceptions enumerees precedemment.
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AUTHORIZATION
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AUTORISATION
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2. I authorize
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2. J'autorise
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(Name of family doctor)
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(Nom du medecin de famille)
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(Address and telephone number)
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(Adresse et numero de telephone)
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To release to Canadian forces medical
personnel, medical information on
Any of the responses in Section 2B.
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A communiquer au personnel medical des
Force canadiennes des
Renseignements sur l'une ou l'autre des
responses de la Section 2B.
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3. Authority is
granted for my son/daughter/ward to receive medical or dental
treatment, at any time, deemed
appropriate by competent medical
personnel, including inoculation and/or
vaccinations deemed necessary by
the Surgeon General.
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3. J'autorise mon
fils/ma fille/mon ou ma pupille a recevoir les soins medicaux
ou dentaires d'urgence juges necessaires
par le personnel medical ainsi
que totu vaccin ou injection prescrit
prescrit par le Chef du Service de sante.
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4. I authorize any
doctor, medical clinic or center to forward to the Medical
Clinic of the Cadet Summer Training
Centre (CSTC) the following
Information concerning my
son/daughter/ward : medical notes, document
Summary, lab test results, x-rays and
any other information contained in the
Medical file and deemed necessary by the
medical authority responsible for
The CSTC for medical care or treatment
provided while he/she carried out
Cadet activities at the CSTC.
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4. J'autorise tout
medecin, clinique ou centre medical a faire parvenir a la
clinique medicale du Centre
d'instruction d'ete des Cadets (CIEC) les
renseignements suivants concernant mon
fills/ma fille/mon ou ma pupille :
notes medicales, resume de dossier,
resultats de test du laboratoire, rayons
X et tout autre renseignement contenu au
dossier medical et juge
Necessaire par l'autorite medicale
responsible du CIEC pour des soins ou
Traitements recus lors de sa
participation aux activities de cadets du CIEC.
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(Signature of Cadet – Signature du
cadet)
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(Signature of
Parent / Guardian – Signature du Parent / Tuteur)
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(Date)
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Tel. No. – Nº de telephone
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(Business –
Travail)
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(Home - Domicile)
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PART 5 – REVIEW /
REGIONAL SURGEON
(Include any restrictions imposed on the cadet due
to a medical condition)
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PARTIE 5 –
REVISION / MEDECIN-CHEF DE LA REGION
(Inclure toute limitation imposee au cadet a cause
d’un probleme medical)
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Fit for all cadet
activities.
Apte a participer a
toutes les activities de cadets.
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Yes
Oui
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No
Non
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Restrictions:
Limitations:
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(Signature)
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(Date)
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PROTECTED A (when
completed) – PROTÉGÉ A (une fois rempli)
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