PART 1 – APPLICATION (To be completed by cadet and parent or guardian)
SECTION “A” – PERSONAL DATA – RENSEIGNEMENTS PERSONNELS
Rank:
Surname:
First Name:
Sex:
Male
Female
Address:
City:
Province:
Postal Code:
Telephone:
Health Number:
Age (as of 01 Jan 2004):
Date of Birth (ie. 26 Mar 1993):
Primary Language:
Other Languages:
Religion:
SECTION “B” – LHQ TRAINING / COURSES / EXCHANGES ATTENDED OR PREVIOUS EMPLOYMENT
Last Training Level Completed:
Training Completed at:
Year Level Completed:
Past Course 1:
Completed:
Location:
Past Course 2:
Completed:
Location:
Past Course 3:
Completed:
Location:
Past Course 4:
Completed:
Location:
SECTION "C" - CADET ACTIVITY(IES) REQUESTED
1st Requested Course:
Location:
2nd Requested Course:
Location:
3rd Requested Course:
Location:
SECTION "D" - DECLARATION OF PARENT OR GUARDIAN
1. I give my consent to my son/daughter/ward to attend the requested cadet activity(ies):
Yes
No
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.:
Yes
No
3. Permission is granted to issue weekend pass and/or evening pass.:
Yes
No
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.:
Yes
No
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.:
Yes
No
PARENT'S ADDRESS AND PHONE NUMBER (if different than section A above)
Address:
City:
Postal Code:
Province:
Phone:
IF PASSES AUTHORIZED ONA RESTRICTED BASIS, INDICATE:
Person to be Visited:
Address:
City:
Province:
Postal Code:
Phone:
PARENT/GUARDIAN SUMMER ADDRESS (if applicable)
Summer Address:
City:
Province:
Postal Code:
Phone:
ALTERNATE FAMILY/ADULTCONTACT (In case of emergency)
Alternate Contact Name:
Address:
City:
Province:
Postal Code:
Phone:
PART 2 – MEDICAL INFORMATION (To be completed by the parent / guardian)
Blood Group:
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.  
2. Does your son/daughter/ward have a medical condition or problem requiring access, within 20-30 minutes, to specialist physician or general practitioners?:
Yes
No
3. If a specialist physician is required, specify the type.:
4. Is your son/daughter/ward being treated or managed by a physician for any of the following:  
a. lung disease, chronic cough, wheezing or asthma?:
Yes
No
b. heart problems?:
Yes
No
c. bed wetting?:
Yes
No
d. seizure disorders, fits, convulsions, epilepsy?:
Yes
No
e. diabetes?:
Yes
No
f. arthritis or other joint problems?:
Yes
No
g. foot problems that may restrict activities?:
Yes
No
h. any condition requiring a special diet?:
Yes
No
i. serious allergeries (to bee stings or other insects, or to drugs such as penicillin)?:
Yes
No
j. any skin conditions that could restrict activities?:
Yes
No
k. any other medical condition not listed above, especially if they may limit activities:
Yes
No
l. dental problems?:
Yes
No
Is your son/daughter/ward on any prescribed medication (including allergy serum, ie, Anakit or EpiPen)?
Please specify, listing the type and dosing strength/intervals:
Is your son/daughter/ward currently undergoing physiotherapy, counseling or therapy for any reason?
Please identify/specify:
Has your son/daughter/ward ever been hospitalized and/or undergone any operation? For what reason and when:
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.):
Doctor's Name:
Doctor's Address:
Doctor's Phone:
Parents Work Phone:
Parents Home Phone: