ADMINISTRATIVEINFORMATION

FOR

COLLEGEPROGRAMSTUDENTS

2014

COLLEGEPROGRAMADMINISTRATIVECHECKLIST

Makesuretofillouteachformtothebestofyourability,andthenpresenttheformsatorientationeitheron9August2014or22August2014.Copiesofthecompleteddocumentsshouldbemadeforyourownrecords.Pleasereturnthecompletedforms and photocopiesoftherequiredpersonalinformationatorientation.Ifyou are not planningon participatingin NROTC, pleasecontact usimmediatelyat

(203)432-8223 and do notfillout anypaperwork.

Pleaserefertotheinstructionsincludedinthisdocument.Formstobefilledout:

AnnualCertificate ofPhysicalCondition

AuthorizationforReleaseofStudentInformationtoParents

AuthorizationforReleaseofStudentHealthInformation

AuthorizationforReleaseofStudentAcademicInformation-School toUnit

DrugandAlcoholAbuse StatementofUnderstanding

NavyTattooScreeningForm

EmergencyContactInformationForm

MidshipmanBackgroundInformationForm

TheConceptof Honor

MCRCOfficerTattooScreeningForm–MarineOptionONLY

NROTCCollegeProgramApplication

PrivacyActStatements(2copies)–bothneedoriginalsignature

NROTCStandardReleaseForm

ReportofDentalExamination

ReportofMedicalHistory

RequiredPersonalInformation:

Letterfromyour physicianstatingthat youarefittoparticipateinphysicalactivity(“sportsphysical”isacceptable,but must be signedbyaPHYSICIAN)

BloodTypeIdentification(DoctororRedCrosscard)

OriginalorCertifiedcopyofBirthCertificate(certifiedcopywithraisedseal)

CopyofSocialSecuritycardwithsignature

Copyofvaccinationrecords(maybefaxedoremaileddirectlyfromyour physician)

Copyofcurrenthealthinsurancecard(bothfrontand back)

Copyofprescriptioninsurancecard(if youhaveone)

Contact theYaleNROTC Unit with questions

Phone:(203)432-8223

Fax:(203)432-8951

Email:

Website:

InstructionsforAdministrativeForms

Theseforms are requiredforentryinto theNROTC Programat Yale. Thedates on theseforms should reflect thefirst dayofFreshmen Orientation: 09 AUG2014 or 22 AUG2014(whichever date of orientation you will be attending).

Annual CertificateofPhysicalCondition

•Writedateat thetop of thedocument (09 AUG2014 or 22 AUG2014).

•Blocks 1 and 2: self- explanatory, use lastfour ofSSN

•Block 3: MIDN

•Block 4: disregard

•Block 5 through 8: self-explanatory

•Block 9: NROTC Yale/63292

•Blocks 10 and 11: Usepermanent addressand phone number

•Blocks 12 through 17:Fill out accordingly.

•Block 18: disregard

•Blocks 2324: Fill outaccordingly.

•Block 19, for femalesonly.

•Leaveother blocks blank unlessyoupossessa record ofthe informationrequested.

•Answer thequestions onpage two truthfullyand sign first, middle, andlastname next to“Member’sSignature.”

AuthorizationforReleaseofStudent Information toParents

•This documentauthorizesrelease of StudentInformationtoParents.

•Printyour first, middle, andlastname after 4/C.

•Sign with fullname:first,middle,andlast.

•Date: 09 AUG2014 or 22 AUG 2014.

•Under signature;yourgraduationyearwill be2018.

•The signing ofthisdocumentis voluntary. Ifyouchoose not toauthorize the Unit toreleaseinformationto your parentsplease write “Decline” on the formand initial it.

Authorization forReleaseof Student Health Information

•This documentauthorizesrelease ofyour sportsphysical, held byyourschool’s healthservice, to theunit.

•Printyour first, middle, andlastname after 4/C.

•Sign with fullname:first,middle,andlast.

•Date:09AUG2014or22AUG2014.

•Undersignature, writeinthelast fourdigits ofyoursocial securitynumberoryourcollegeIDnumber;forthe class of,it will be2018.

Authorization forReleaseof Student AcademicInformation- Schoolto Unit

  • This documentauthorizesrelease of studentinformationfromyourrespective universityto the Yale NROTC unit.
  • Printyour first, middleandlastname after 4/C.
  • Sign with fullname:first, middle andlast.

Date: 09 AUG2014 or 22 AUG 2014.

  • Under signature,writeinthe lastfour digits ofyour social securitynumberoryour college
  • IDnumber; forthe classof, it will be2018.
Thesigning ofthisdocumentis voluntary. Ifyouchoose not toauthorize unit toreleaseinformationtoyour parentsplease write “Decline” on the formand initial it.

DrugandAlcoholAbuse StatementofUnderstanding

  • Printyour first,middle,andlastname.
  • Readeachsection carefullyandunderstand the importance of eachstatement. Initialwith first,middle,andlastinitial inthe boxnext tothestatement(Blocks1-5a).
  • Note: 5b disregard.
  • Under Certification:Printlast,first, middlename,andwriteyoursocial securitynumber.
  • Sign and datethedocument: 09 AUG2014 or 22 AUG 2014.
Wewill reviewthisdocumentatFreshmenOrientationtoconfirmyour understandingand certifythat your signature is true.
  • Self-explanatory

NavyTattooScreeningForm

EmergencyContactInformation Sheet

  • Self-explanatory.
  • Sign and datethebottom of the sheet:09 AUG2014 or 22 AUG 2014

MidshipmanBackgroundInformationSheet

  • Self-explanatory.
  • Fill in “CampusData”section if information isknown, otherwise disregarduntil Orientation.

The ConceptofHonor

  • Besureto readandunderstand the significance ofthis document.
  • Signyour fullname:first,middle,andlastabove “Signature of midshipman”.
  • Datetheform 09 AUG2014 or 22 AUG 2014.

MCRCOfficerTattoo ScreeningForm

  • MARINEOPTIONONLY– Purpose ofthis form is to certifythatyouhave disclosedthe fullextent ofanytattoos,brands orbodyornamentation to include those removed oraltered.
  • Printyourfirst, middle, and last name. Date:20140809 or 20140822
  • PartI,Question 1: Readandanswer the questionusingyourFirst, Middle, andLastInitials.
  • Iftheanswerto Question1 is “No”,proceed to PartII; signand date“20140809 or 20140822”.Disregard PartIII,IV, and V.
  • Iftheanswerto Question1 is “yes”, continueansweringQuestions 2 through 9. Signand datePartII“20140809 or 20140822”.
  • NOTE: ifthe answer toQuestion 1 is “yes”youmust be interviewedbya

commissionedofficer uponarrivingatUnit.

  • Self-explanatory.

NROTCCollegeProgramApplication

  • Sign and Datedocument: 09 AUG2014 or 22 AUG 2014.
  • NOTE:Ifyou havepreviouslyfilled out and submitted the application,youdo not need toresubmit.

PrivacyAct Statement

  • Readeachsection carefullyto understand the reasoningfor documentinghealth care.
  • Sign the form withyourfirst, middle, andlastname.
  • Fill inyoursocial securitynumber(last four)anddate:09 AUG2014 or 22 AUG 2014.
Print, signand dateTWO copies(one for healthrecord and oneforDentalrecord).

NROTCStandardReleaseForm

•Self-explanatory.

ReportofDentalExamination

  • Blocks 12: Self-explanatory.
  • Blocks 3 -16: Must be completedbydentist.
  • Ifadental exam hastakenplace within the last year anewexamis not necessary.
  • ThisformmaybefaxedoremailedtotheUnitdirectlyfromyourdentalprovider’soffice.

Reportof Medical History

  • Blocks1-5:Self-explanatory.
  • Block 6: Navy,and Other, writein “NROTCCollege Program”.
  • Answer allquestionstruthfully.
  • Block 30:Leave blank. Yourphysician will indicate thatyouare fitfor physicaltrainingin their own letter.

InstructionsforRequiredPersonalInformation

Thesedocumentsare required for entryinto theNROTC ProgramatYale. In mostcases,photocopies ofthe originaldocuments will be sufficient,exceptfor proofof citizenship.Seespecific guidance below.

Letterfromyour physicianstatingthat youarefittoparticipateinphysical activity.A“sportsphysical”isacceptable; however,it must besignedbyaPHYSICIAN.

BloodTypeIdentification(DoctororRedCrosscard),requiredforallsummertraining

evolutions.

OriginalorCertifiedcopyofBirthCertificate(certifiedcopywithraisedseal).Bringtheoriginal document with youtoOrientation. Wewillneedtosee(inperson)theoriginal or certifiedcopyof yourBirthCertificate(FS240,orDD1350forcitizensbornabroad),sothatwecancertifythecopyforourrecordsasatruecopy.

Birthcertificatesmustmeetallofthefollowingcriteria:Fullname (first,middle,last),birthdate,birthplace,birthrecordvalidationsuchasanoriginalormachineproducedsignatureorraised,impressed,embossed,multicoloredsealorstamp,oracombinationoftheseisacceptable.

CopyofSocialSecuritycardwithsignature

Copyofvaccinationrecords(maybefaxedoremaileddirectlyfromyour physiciantotheNROTCUnit)

Copyofcurrenthealthinsurancecard(bothfrontand back)

Copyofprescriptioninsurancecard(if youhaveone)