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					                Army ROTC Enrollment Forms
This excel spreadsheet has the forms to enable you to become an Army ROTC Cadet at
University of Illinois at Urbana-Champaign. Please save the form under your name:
(ex: your name is Katie Brown. Save the excel spreadsheet "Katie Brown).

Once you save this on your computer under your name begin by clicking on the worksh
"Cadet". Follow the instructions to the left of the form in the yellow box.

The medical forms labeled either in UIUC or Non-McKinley are for you to print up and
physician or Convenient Care. There are yellow box instructions on the sheets to help y
you how the forms need to be completed.

If you have any questions, feel free to contact us at 217-244-1407 or email arotc@illino

When you are finished filling out the forms and printing the forms you need, please sen
arotc@illinois.edu.
y ROTC Cadet at the
nder your name:


ng on the worksheet that says


ou to print up and to take to your
he sheets to help you either fill out or instruct


mail arotc@illinois.edu

 need, please send the completed forms to
                                                                                                                  PROSPECT/CADET INFORMATION
            ROTC School: University of Illinois at Urbana-Champaign                                             School of Attendance:                                               -                                              Attend. FICE Code:                        -

 ROTC Fice:         001775                                                                                                                                                                                               (001775 or 007118                      UIUC or Parkland)
                                                                                                                                                                                                                                                                                           Directions: Complete this document by filling
Name:                                                                        -                                                                             SSN:                                        -
                                                                                                                                                                                                                                                                                           with the information requested to the left. On
UIN                                       -
                                                                  (Last, First, Middle)

                                                                             (U of I students only)                                                    Net ID:
                                                                                                                                                                                                (xxx-xx-xxx)

                                                                                                                                                                                                             -                                                                             sheet is done, it will populate the sheets in thi
Card Number: (16-digit number on I-Card                                                                                                     -                                                                                                                                              for SAL Statement. Fill this form out if you do
Local Address:                                                                   -
                                                                             (School Address)
                                                                                                                             City                                   -                         State          -                   Zip Code                             -                    Scholarship). You will then email the forms to
Email Address:                                                                           -                                                                 Cell Phone #:                                      -
                                                                                                                                                                                                      (xxx) xxx-xxxx
                                                                                                                                                                                                                                                                                           arotc@illinois.edu. When you arrive on camp
Permanent Address:
                                                             (Permanent Home Address)
                                                                                         -                                                 City                              -                               State       -                    Zip Code                       -
                                                                                                                                                                                                                                                                                           forms and fill out any other pertinent portions.
Perm. Phone                                              -
                                          (xxx) xxx-xxxx                                                                                                                                                                                                                                   the MEDICAL FORMS that apply to you (see
 Sex:         -              Height:             -                           Weight:            -                    Hair Color:                            -                               Eye Color:                       -
            (M/F)                             (inches)                                         (lbs)                                                      (color)                                                        (color)                                                           Instructions), set up an appointment with your
        Religious Pref:                                                          -                                                                                      Blood Type:
                               (Denomination or Religion) More specific than Christian please.                                                                                                             (A/B/O,Pos/Neg)                                                                 sports physical. You must have a new physic
Date of Birth:                     -                                                         Place of Birth:                                                                 -

        Marital Status
                           (day/month/year)
                               -                                 Dependents:                    -          How Many:             -
                                                                                                                                                                    (City/County/State)
                                                                                                                                                             Spouse member of armed forces:                                        -
                                                                                                                                                                                                                                                                                           Federal Scholarship and DODMERB Qualified
Race/Ethnicity:
                            (S/M/D/W)
                                   -      African American                   US Born
                                                                                             (Y/N)
                                                                                             Citizenship:               -
                                                                                                                                (#)                                                                                              (Y/N)
                                                                                                                                                                                                                                                                                           requirement.
Check One                          -      American IndianCheck One           Naturalized                                -
                                   -      Asian                              Born overseas to US parents                -
                                   -      Caucasian                          Immigrant alien                            -
                                   -      Hispanic                           Non immigrant alien                        -
                                   -      Other: -                           Refugee                                    -
                                                                       PHYSICAL / MEDICAL INFORMATION
Do you have a medical condition that could interfere with physical training?          -     Do you have:                                                                                Asthma:                    -     Allergies:            -        On Meds:             -
                                                                                                                                           (Y/N)                                                                 (Y/N)                       (Y/N)                         (Y/N)
                If Y, explain: -
Ever received medical disability payments from any source                                                               -
                                                                                                                    (Y/N)
                       If Y, explain: -
24. NEXT OF KIN (NOK)                                                                    -                                                        24a. NOK ADDRESS:                                                                      -

    24b. NOK PHONE NO                                                    -                          (Use cell if that is the fastest way to get in touch with them)
                                                                                                                  ACADEMIC INFORMATION
Academic Major:                                              -                                   Academic Minor:                        -                        SAT:                                                        -                       ACT:             -
                                              (per course catalog)                                                                                (per course catalog)                                             Reading & Math                                Composite
Academic Standing:                               -                       Proj Grad Date:                                -                             Credits required for degree:                                                 -         UI Students: Use Program of Study online
                                       (FR/SO/JR/SR/GR)                                                      (day/month/year)
Credits earned towards degree:                                     -                         cGPA College:                             -                                    Years Attended (Coll)                                  -                       All colleges.
                                                 (include transfer credits)

Other College attended:                   -                                                                                                                                                                            IL Resident?:           -     R=IL Resident/N=Not IL Resident
                                                                                                                        (name/state)                                                                                                         (R/N)
High School Attended:                     -                                                                                                                                 HS GPA:               -          Date Graduated from HS:                                         -
                                                                                                    (name/city/state)                                                                         (4.0 scale)                                                         (day/month/year)
                                                                                                                        SCHOLARSHIP INFORMATION
ROTC Scholarship Recipient:                                        -             What Type:                                     -                                                               Mission Set Awarded In:                                     -
                                                                 (Y/N)                                          (# of years, CBSP/LTC/GRFD/GTG/Ded ARNG)
Other Scholarship(s)           -
                                                                                                                                                (Name and benefits of scholarship):
                                                                                                                   LATERAL ENTRY INFORMATION
JROTC Experience:                                -                                   If Y, type JROTC program and number of years: -
                                               (Y/N)
If you are not nor have ever been in the Armed Forces, any ROTC and/or a Service Academy check here:                                                                                                               -     (Skip to Scholar/Athlete/Leader Section)

If you have been in the Armed Forces, please complete this section. And you must answer the first question "Y". Otherwise check the box above and continue to Scholar/Athlete/Leader Section
In the Armed Forces (incl ARNG/USAR):                                                -                  What branch:                              -                       Unit: -
                                                                                 (Y/N)                                                                                                                                       (Name/Address/Phone #)
Spouse in the Armed Forces:                                        -
                                                             (Y/N)
Ever discharged from the Armed Forces:                                               -                  What branch:                              -                              Type Discharge:                                   -                    RE Code:                   -
                                                                                 (Y/N)                                                                                                                                 (DN/OTHD/CBD/DD)                                    (See DD 214)
Months Active Service:                           -                               Ever medically discharged:                      -                If Y explain:                                                                          -
                                                (#)                                                                            (Y/N)
Ever enrolled in an officer producing program:                                                  -                  Ever Disenrolled from ROTC?                                          -
                                                                                              (Y/N)                                                                                 (Y/N)
Ever enrolled in a service academy:                                                  -                          If Y, which one: -
                                                                                 (Y/N)
Ever disenrolled from an officer producing program:                                                         -               If yes, where: -
                                                                                                        (Y/N)
                                                                                                                    SCHOLAR / ATHLETE / LEADER
Please checkmark those you have participated in high school or college. Please use the SAL Statement to let us know what activities and how many years. The sheet will have directions.

                                              High School                                                                                                                                                    University
                    GPA>3.0 & SAT/ACT > 1100/21                                                                         -                                               Academic Honors Program designee                                                                               -
                    Top 10% class & SAT/ACT > 1100/21                                                                   -                                               Top third of class & GPA > 3.0                                                                                 -
        S           Honors/Advanced Placement Program Grad                                                              -                             S                 Top third of class & & SAT/ACT > 1100/21 (Fresh/G2G)                                                           -
                    Membership in National Honors Society                                                               -                                               GPA>3.0 & SAT/ACT > 1100/21 (Fresh/G2G)                                                                        -
                    Valedictorian/Salutatorian                                                                          -                                               Engineering , technical, science or Nursing Major?                                                             -
                    Varsity Letter                                                                                      -                                               Member intramural team                                                                                         -
        A           Member city/regional/competitive league                                                             -
                                                                                                                                                      A                 Member city/regional/competitive league                                                                        -
                    Member organized team/individual sport                                                              -                                               Member organized team/individual sport                                                                         -
                    Elected member of student organization                                                              -                                               Member of university sports program                                                                            -
                    Captain of athletic team                                                                            -                                               Elected member of student organization                                                                         -
        L           Eagle Scout/Gold Star                                                                               -                                               Captain of athletic team                                                                                       -
                    Position of responsibility in club/organization                                                     -                             L                 Eagle Scout/Gold Star                                                                                          -
                                                                                                                                                                        Position of responsibility in club/organization                                                                -
                                                                                                                                                                        Owns/runs own business or in supervisory position                                                              -
Directions: Complete this document by filling in the aqua spaces
with the information requested to the left. Once this "Cadet"
sheet is done, it will populate the sheets in this workbook (except
for SAL Statement. Fill this form out if you do not have a Federal
Scholarship). You will then email the forms to:
arotc@illinois.edu. When you arrive on campus, you will sign the
forms and fill out any other pertinent portions. Please print out
the MEDICAL FORMS that apply to you (see Medical
Instructions), set up an appointment with your doctor to have a
sports physical. You must have a new physical. If you are
Federal Scholarship and DODMERB Qualified, you will skip this
requirement.
    SCHOLAR, ATHLETE, LEADER STATEMENT
Name:                                                        Date:

For each section, list the activity or achievement. For clubs and athletics, indicate how many
years you have been participating in that activity.(for example: National Honor Society – 2
years; Football – 4 years, Captain of team 2-years; Worked at McDonalds – 2 years, worked as
a manager 1 year.)

Scholar – Academic Excellence (GPA over 3.5, National Honor Society, Academic Awards, etc.)




Athletic (sports you have participated, whether city or school (college or high school), practices
you have adopted to your lifestyle (running 5 miles, etc)




Leader (participated in clubs or in a leadership position in an organization, manager of a team or
at work):




Where do you see yourself in 5-10 years?
                                                                                                                      CADET ENROLLMENT RECORD
                                                                                                  For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PC
                                                                                                               DATA REQUIRED BY THE PRIVACY ACT OF 1974
Authority                               10 USC 2101, 2103, 2104, 2107, 2111, and 5 USC 301
Principal Purpose(s)                    To obtain personnel data in order to determine eligibility for enrollment and serve as a source document for cadet's service record throughout participation in the ROTC Program. Provides data for the
                                        administration of the ROTC student commencing with application for enrollment into the ROTC Program.
Routine Uses                            To verify eligibility to participate in the ROTC Program; to provide information on addresses and telephone numbers for use in the event of death, injury, illness or unauthorized absence while
                                        participating in ROTC activities; to facilitate contact with complete information with a cadet during other than normal training periods; to make a matter of record the information provided by the cadet.
Disclosure                              Disclosure is voluntary. However, failure to provide complete information and provide responses will suspend the enrollment process into the ROTC Program.
                                                                                                                       PART I - GENERAL INFORMATION
1. NAME                                               -                                           2. SSN                    -           3. COLLEGE ID#                    -                  4. EMAIL        -

5. LOCAL ADDRESS            -                                                                      5a. CITY -                                               5b. STATE         -              5c. ZIP CODE -                       6. PHONE NUM       -

7. PERMANENT ADDRESS                    -                                                          7a. CITY -                                               7b. STATE         -                             7c. ZIP CODE -                     8. PH NUM -

9. DOB         -                     10. POB                                          -                                                 11. RELIGIOUS PREF -                                        12. BLOOD TYPE        0          13. ACT -           14. SAT -

15. SEX            -   16. HEIGHT       -                        17. WEIGHT -                      18. MARITAL STATUS -                                           19. DEPENDENTS -                               19a. NUMBER OF DEPENDENTS -

20. RACE/ETHNICITY (Check One)                    -       African American            -    American Indian              -       Asian                -      Caucasian                    -   Hispanic                 -   Other         -

21. CITIZENSHIP (Check One)                               U.S. Citizen:          -   U.S. Born             -    Naturalized              -       Born Overseas With U.S. Parents                                   Dual Citizenship (See CC PAM 145-4, 2-39)

                                                          Non U.S. Citizen:           -    Immigrant Alien              -       Nonimmigrant Alien                                -    Refugee

22. Do you have any condition that could interfere with you participating in a normal college physical education course?                             -           22a. If "yes" explain -



23. Have you ever received Medical Disability payments from any source?                     -        23a. If "yes" explain -

24. NEXT OF KIN        -                                                                           24a. ADDRESS -                                                                                                                           24b. PHONE NO -

                                                                                                                      PART II - ACADEMIC INFORMATION
25. ROTC HOST SCHOOL                    University of Illinois at Urbana-Champaign                25a. FICE CODE 001775                              26. SCHOOL OF ATTENDANCE -                                                                     26a. FICE CODE -

27. RESIDENCY STATUS                        -                 28. ACADEMIC CLASS      -                         29. PROJECTED GRADUATION DATE -                                          30. ACADEMIC MAJOR -

31. ACADEMIC MINOR          -                                                                    32. CREDITS TOWARD DEGREE -                                      33. CREDITS REQUIRED FOR DEGREE -                                 34. CGPA (COLLEGE)

35. OTHER COLLEGES ATTENDED                               -                                                                                      35a. YEAR(S) ATTENDED            -           36. HIGH SCHOOL ATTENDED -

36a. GRADUATION DATE                    -                                                 37. ROTC SCHOLARSHIP RECIPIENT                     -                                           37a. If "yes" what type? -

38. OTHER SCHOLARSHIPS                  -                                                                                                                                                     39. JROTC EXPERIENCE

                                                                          PART III - CURRENT OR PRIOR MILITARY SERVICE (TO INCLUDE OFFICER PRODUCING PROGRAMS)
          -    NOT APPLICABLE (Go to PART IV)                                  40. CURRENT SERVICE:                  Are you currently in the Armed Forces?           -               40a. If "yes" which Branch? -

40b. SMP UNIT          -                                                                                                                                                                             40c. Is your spouse currently a member of the Armed Forces?          -

41. PRIOR SERVICE:                   Have you ever been enrolled in an officer producing program?          -                      41a. Were you ever disenrolled from the ROTC Program?                 -

41b. Were you ever enrolled in a Service Academy?                          -     41c. Were you ever discharged from the Armed Forces?                -          41d. If "yes" what type of discharge? -                      41e. If "yes" what was the RE Code? -

41f. Months of Active Service               -         41g. Have you ever been discharged for medical reasons?           -                41 h. If "yes", explain: -



CC Form 139-R, DEC 07                                                     REPLACES ALL PREVIOUS EDITIONS, WHICH ARE OBSOLETE.                                                                                                                                    Page 1 of 6
                                                                                                                                                                                                                        Name -
                                                                                              CADET ENROLLMENT RECORD
                                                                                                                                                                                                                                                  SSN -
                                                                                                                         PART IV - STUDENT STATEMENTS
42. RELEASE OF INFORMATION
The Privacy Act requires that we notify you of other routine uses of the information we collect from you. You should know that if you leave school, we might provide your name, address, and phone number to the U.S. Army
Recruiting Command. This is done because the Active Army, Army Reserve, and National Guard want and need intelligent young men and women. They also have programs which might help you return to college. The
transfer of information to the Recruiting Command means that, if you drop from school, you may receive information in the mail or be called by an Army Recruiter. You are under no obligation to accept the mail or to talk to the
recruiter.
               I have read and understand the above statement concerning data required by the Privacy Act of 1974.

Verification of the following statements is required in order to assist in establishing eligibility to participate in the ROTC program. Failure to provide a response will preclude further processing as an enrolled cadet. Failure to provide
an accurate or truthful response is grounds for barring entry into the SROTC program or for the initiation of disenrollment action. Your signature at the bottom of this page will attest to the accuracy of your responses on this form.

43. STATEMENT OF CRIMINAL PROCEEDINGS BY CIVIL OR MILITARY AUTHORITIES
I have not been indicted or summoned into court under civilian or military law as a defendant in a criminal proceeding, to include any and all proceedings involving juvenile or adult criminal offenses, but excluding minor traffic
violations (Exception: alcohol-related driving offenses) which involved a fine or forfeiture, alone, of less than $250. I have not had 6 or more minor traffic violations (excluding parking violations) in a 12-month period where the fine is
$100 or more per offense. I have not had 12 or more minor traffic violations (excluding parking violations) during the previous 3 years where the fine is $100 or more per offense. I have never been convicted, fined, imprisoned,
placed on probation, paroled, or pardoned (to include alcohol violations and misdemeanors), except for minor traffic violations as defined above. I will advise the Professor of Military Science of any future information pertaining to
any changes of criminal conduct against myself and I shall do so as soon as practical under the circumstances. Records that are expunged, sealed, set aside, dismissed, or original findings or pleas changed STILL require a waiver.
Check One:
               The above statement is true.                              The above statement is not true - Explain:

44. SUBSTANCE ABUSE
              Check One:                         I have never used an illegal substance or drug.

                                                 I have used illegal substances or drugs only on an experimental or limited basis.                      When:                                                                     How Often:

                                                 I have been a recent or frequent user of illegal substances or drugs.                                  When:                                                                     How Often:
NOTE: Any future drug use will be grounds for disenrollment from the ROTC Program.

45. RELIGIOUS ACCOMMODATION
The U.S. Army cannot guarantee that my religious practices will be accommodated. I acknowledge and understand that it is the Department of the Army's policy to accommodate religious practices as long as the practice will
not have an adverse impact on military readiness, unit cohesion, standards, health, safety or discipline. I further acknowledge and understand that the U.S. Army has the right to amend or eliminate any such accommodation
based on the needs of the Army.
               I have read and understand the above statement concerning accommodation of my religious practices.
46. CONSCIENTIOUS OBJECTION
If you have moral convictions that preclude you from bearing firearms and/or participating in full military service with the U.S. Army, to include armed combat, then you are a conscientious objector. AR 600-43 defines
conscientious objection as "A firm, fixed and sincere objection to participation in war in any form or the bearing of arms, because of religious training and belief."
         Check One:                       I am not a conscientious objector.                       I am a conscientious objector.               Explain:

47. DOD HOMOSEXUAL CONDUCT POLICY BRIEFING
Although you have not been asked nor will you be asked about your sexual orientation, you should be aware of the DoD Homosexual Conduct Policy. Homosexual conduct is grounds for barring entry or continued enrollment in the
SROTC Program. Homosexual conduct is a homosexual act, a statement that demonstrates a propensity or intent to engage in homosexual acts, or a homosexual marriage or attempted marriage. A homosexual act means any
bodily contact, actively undertaken or passively permitted, between members of the same sex for the purpose of satisfying sexual desires and any bodily contact that a reasonable person would understand to demonstrate a
propensity or intent to engage in such an act.

I understand I will be disenrolled from the SROTC Program if one or more of the following findings is made:
a. I have engaged in, have attempted to engage in, or have solicited another to engage in homosexual act or acts.
b. I have made a statement that demonstrates a propensity or intent to engage in homosexual acts.
c. I have married or attempted to marry a person of the same sex as myself.
FOR ENROLLMENT OFFICER USE:                              Ask the following questions to ensure the applicant understands this policy and expand on the policy, as necessary: (1) Do you fully understand the DoD Homosexual
Conduct Policy briefing you have read? (2) Do you have any questions concerning this policy?
               I have read and understand the briefing concerning the DoD Homosexual Conduct Policy.


 "All information given on this form is correct to the best of my knowledge."                              SIGNATURE OF CADET

48. LOYALTY OATH (OPTIONAL FOR NONCONTRACTED CADETS)
" I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States of America against all enemies, both foreign and domestic; that I will bear true faith and allegiance to the same, and that I take
this obligation freely, without any mental reservation or purpose of evasion, so help me God."


               SIGNATURE OF CADET                                                                                                                                                     DATE


CC Form 139-R, DEC 2007                                                                                                                                                                                                                                   Page 2 of 6
                                                                                                                                                                                                                            Name -
                                                                                                  CADET ENROLLMENT RECORD
                                                                                                                                                                                                                                                  SSN -
                                                                                                   PART V - BASIC COURSE ENROLLMENT ELIGIBILITY CHECKLIST*
ALL NONCONTRACTED CADETS MUST MEET THE FOLLOWING CRITERIA TO ENROLL IN THE BASIC COURSE:
Enrollment Eligibility Officer: Verify the criteria below and sign the certification on page 5.
49. ACADEMIC STATUS                                       Eligible: Registered for and attending full time (in accordance with university policy - usually 12 or more credit hours) a regular course of instruction resulting in an accredited undergraduate
                                                                      or graduate degree at a host or partnership school.
                                                          Ineligible (Waiver denied): Not registered for and attending full time a regular course of instruction at a host or partnership school.


50. CONSCIENTIOUS OBJECTION                               Eligible: (a) U.S. Citizen and is not a conscientious objector. (b) Enrolled alien student (exempt by statute). (c) Students required by their school to take military training.

                                                          Ineligible: Student is a U.S. Citizen and a conscientious objector at a school, which does not require its students to take military training. (NOTE: Prior to enrollment students who have
                                                                        previously been conscientious objectors must furnish a letter stating they no longer have convictions that preclude bearing arms and participating in full military service with
                                                                      the U.S. Army).

51. CHARACTER                                             Eligible: Good moral character. No domestic violence conviction.

                                                          Ineligible: Nonwaiverable. Domestic violence misdemeanor or felony conviction.


52. TATTOOS                                               Eligible: Student does not have any tattoos specifically prohibited by Army policy (see ineligible below).

                                                          Ineligible: (a) Any tattoo/brand on the face, neck or head (permanent facial makeup that conforms to AR 670-1 makeup standards is permitted). (b) Other tattoos/brands that are visible and
                                                                       that detract from a soldierly appearance while wearing the Class A uniform. (c) Other tattoos/brands that are prejudicial to good order and discipline.

53. CITIZENSHIP                                           Eligible: U.S. Citizen (Must be verified per instructions). (Dual citizens must renounce foreign citizenship prior to receiving a clearance (see CC PAM 145-4, 2-39a)).

                                                          Approval Required: (a) Immigrant Alien (b) Refugee (NOTE: Aliens are ineligible for scholarship and SMP, even if approved for enrollment).

                                                          Ineligible: Nonimmigrant Aliens.                                                                        Approval Granted (Eligible):        Date

54. MEDICAL                                               Eligible: DA Form 3425-R has been completed and signed by a qualified medical physician (or equivalent statement from university health care provider) showing no medical
                                                                    condition/physical impairment that precludes enrollment in the basic course.
                                                          Ineligible (Waiver denied or nonwaiverable): Qualified medical physician refuses to complete and sign DA Form 3425-R for the student.


* NOTE: ENROLLMENT ELIGIBILITY OFFICER WILL CHECK THE INFORMATION IN PARTS I - III AND THE STUDENT'S STATEMENTS IN PART IV AND ADVISE THE STUDENT IF A
WAIVER IS REQUIRED PRIOR TO CONTRACTING I.E., AGE, RE-CODE, DEPENDENCY, CIVIL CONVICTION, SUBSTANCE ABUSE, ETC. (Waiver approval is not guaranteed).
                                                                                                  PART VI - NONSCHOLARSHIP CONTRACTING ELIGIBILITY CHECKLIST
ALL NONSCHOLARSHIP CADETS MUST MEET THE FOLLOWING CRITERIA TO CONTRACT:
Enrollment Eligibility Officer: Verify the criteria below and sign the certification on page 5. (Scholarship students must also meet scholarship eligibility requirements in Part VII)
55. PREVIOUS CRITERIA                                     Eligible: Student meets criteria 49-54 on the Basic Course Enrollment Eligibility Checklist (Part V).


                                                          Waiver Required: Pending waiver for criteria in Part V above.                                           Waiver Granted (Eligible):           Date


                                                          Ineligible (Waiver denied or nonwaiverable).


56. CIVIL CONVICTION                                      Eligible: (a) No civil conviction, adverse adjudication, or court-martial conviction other than minor traffic violations (Exception: alcohol-related driving offenses) resulting in a fine
                                                                    of less than $250. (b) Not guilty verdict or successful appeal of a conviction.
                                                          Waiver Required (Prior to Contracting): Any civil conviction, adverse adjudication, or court-martial conviction other than minor traffic violations (Exception: Alcohol-related driving offenses)
                                                                   resulting in a fine of less than $250. Any conviction resulting in other adverse dispositions (punishment other than a fine) requires a waiver. Convictions where the record is
                                                                     expunged, sealed, set aside, dismissed, or original finding or pleas changed still require a waiver.
                                                                                                                                                                  Waiver Granted (Eligible):           Date

                                                          Ineligible (Waiver denied or nonwaiverable): (a) Pending charges for violating any civil law; (b) On supervised and/or conditional probation.

57. DEPENDENCY                                            Eligible: (a) Single student with no dependents. (b) Married student with no more than three (3) dependents, to include spouse. (c) Single student whose children have been placed by
                                                                    court order in the custody of an adult relative/legal guardian and the student is not required to pay child support.
                                                          Waiver Required (Prior to Contracting): (a) More than three (3) dependents (spouse plus more than 2 children under 18 years old). (b) Single parent whose children have been placed by
                                                                    court order in the custody of an adult relative/legal guardian when the student is required to pay child support. (c) Spouse is also in Army ROTC and there are children under
                                                                    18 years old. (d) Spouse is in a military component of any Armed Service (other than Inactive Ready Reserve) when student has a child under 18 years old.

                                                                                                                                                                  Waiver Granted (Eligible):           Date
                                                          Ineligible (Waiver denied or nonwaiverable): Single parents who have legal custody of their children who are under 18 years old.


CC Form 139-R, DEC 2007                                                                                                                                                                                                                                        Page 3 of 6
                                                                                                                                                                                                                              Name -
                                                                                                CADET ENROLLMENT RECORD
                                                                                                                                                                                                                                          SSN -
ALL NON-SCHOLARSHIP CADETS MUST MEET THE FOLLOWING CRITERIA TO CONTRACT:
Enrollment Eligibility Officer: Verify the criteria below and sign the certification on page 5. (Scholarship students must also meet scholarship eligibility requirements in Part VII.)
58. SUBSTANCE ABUSE                                      Eligible: (a) Never used chemical substances or drugs; (b) Self admitted limited, experimental use of chemical substances or drugs which occurred over 6 months prior to contracting,
                                                                     unless disqualified by DoDMERB.
                                                         Waiver Required: (a) Self admitted use of chemical substances or drugs on an experimental or limited basis, which occurred within six (6) months prior to contracting. (b) Self admitted
                                                                     frequent and/or habitual use of chemical substances or drugs prior to contracting.
                                                                                                                                                                  Waiver Granted (Eligible):           Date
                                                         Ineligible (Waiver denied or nonwaiverable) Chemical substance or drug abuse requiring professional care, which is medically disqualifying.


59. LOYALTY OATH                                         Eligible: Cadet signed loyalty oath.


                                                         Ineligible: Refuses to sign loyalty oath.


60. PRIOR SERVICE                                        Eligible: (a) No prior service. (b) Honorably discharged from the Armed Services with a qualifying RE code of 1 on DD Form 214. (c) Currently in the Army Reserve or National
                                                                   Guard (see NOTE below).
                                                         Waiver Required: (a) Honorably discharged with an RE code other than 1 on DD Form 214.                                  Waiver Granted (Eligible):            Date

                                                         Ineligible (Waiver denied or nonwaiverable): (a) Honorably discharged with a disqualifying RE code on the DD From 214. (b) More than ten (10) years Active Duty, without an exception to
                                                                    policy from CC. (c) Any type of discharge other than "honorable". (d) Current or former commissioned officer, or has a certificate of eligibility for appointment as a commissioned
                                                                   officer. (e) On Active Duty at time of contracting. A soldier on terminal leave is ineligible until actual separation.
                                                                   NOTE: Contracted cadets cannot be in the USAR or ARNG (to include IRR) outside of the SMP program. Upon contracting, current members of the USAR or ARNG must either sign an SMP contract (and remain a member o
                                                                   sign an SMP contract (and remain a member of the USAR or ARNG) or sever ties with their USAR or ARNG unit (the ROTC contract overrides any reserve component contract).

61. CITIZENSHIP                                          Eligible: U.S. citizen. (Dual citizens must renounce foreign citizenship prior to receiving a clearance, which is a prequisite for commissioning (see CC PAM 145-4, 2-39a)).


                                                         Ineligible (Nonwaiverable): Non-U.S. citizen.


62. PLACEMENT CREDIT                                     Eligible: Student is enrolling in the Alternate Entry Program, the Accelerated Cadet Commissioning Training Program, OR student has received credit for MS I & MS II by any combination
                                                                    of the following (as set forth in CC Reg 145-3, Table 6-1): (a) Completed Basic Course. (b) Successfully completed LTC. (c) Completed Basic Training in one of the Armed
                                                                   Services. (d) Credit for Senior ROTC training (Army, Navy, Air Force, Marine, or Coast Guard). The first year of any SROTC = credit for MS I. Any additional years of SROTC =
                                                                    credit for the Basic Course. (e) Participation in a service academy. One year = credit for MS I. Two years = credit for the Basic Course. (f) JROTC experience. One year = no credit.
                                                                    Two years = PMS may award up to MS I credit. Three years = PMS may award up to full Basic Course credit.
                                                         Ineligible (Waiver denied/Nonimmigrant Aliens)


63. ACADEMIC STATUS                                      Eligible: (a) All students must be enrolled full time AND academically aligned AND have a cumulative college GPA (if any) of 2.0 on a 4.0 scale or equivalent. (b) MJC freshman
                                                                   also require at least a 2.0 cumulative high school GPA AND SAT score of 850 or ACT of 17.
                                                         Waiver Required: Graduate student with less than full time enrollment (waiverable).                              Waiver Granted (Eligible):           Date


                                                         Ineligible (Waiver denied): (a) Student is not academically aligned (Exceptions to policy may be considered); (b) Cumulative college GPA is less than 2.0 (nonwaiverable).


64. PHYSICAL FITNESS                                     Eligible: Score 180, with a minimum of 60 points in each event, on a single APFT.


                                                         Ineligible (Nonwaiverable): Failure to meet eligibility criteria.


65. MEDICAL                                              Eligible: Student is fully medically qualified by a DoDMERB physical.


                                                         Waiver Required: Student is medically disqualified by a DoDMERB or MEPS physical, if applicable.                                 Waiver Granted (Eligible):          Date


                                                         Ineligible (Waiver denied or nonwaiverable).


66. AGE                                                  Eligible: Student is at least 17 years of age at time of contracting and will be less than age 30 at time of commissioning.


                                                         Waiver Required (Prior to Contracting): Age 35 or older at time of commissioning. Brigade Commander can waive thru age 39. CG is waiver approval authority for over 39 years of age.
                                                                 NOTE: Retirement benefits are at risk for 33 and higher.                               Waiver Granted (Eligible):        Date


                                                         Ineligible (Waiver denied or nonwaiverable): Student is younger than 17 at time of contracting.

CC Form 139-R, DEC 2007                                                                                                                                                                                                                                      Page 4 of 6
                                                                                                                                                                                                                    Name -
                                                                                                 CADET ENROLLMENT RECORD                                                                                                                 SSN -
                                                                                                              PART VII - SCHOLARSHIP ELIGIBILITY CHECKLIST
ALL SCHOLARSHIP CADETS MUST MEET THE FOLLOWING CRITERIA TO CONTRACT:
Enrollment Eligibility Officer: Verify the criteria below and sign the certification on page 5. Scholarship students must also meet scholarship eligibility requirements. NOTE: Green to Gold scholarship applicants must meet additional
criteria in order to apply. Refer to the current Green to Gold application for details.
67. PREVIOUS CRITERIA                                     Eligible: (a) Four-year and three-year scholarship winners must meet criteria 55-61 on the Advanced Course Eligibility Checklist (Part VI). (b) Two-year scholarship winners must meet
                                                                      criteria 55-62 on the Advanced Course Eligibility Checklist (Part VI). (NOTE: Alternate Entry Option students are ineligible for scholarship).
                                                          Ineligible: Ineligible for contracting unless student is fully qualified.


68. MEDICAL                                               Eligible: Student is fully medically qualified by DoDMERB.

                                                          Waiver Required: Student is medically disqualified by DoDMERB.                                     Waiver Granted (Eligible):        Date

                                                          Ineligible (Waiver denied or nonwaiverable).

69. MAJOR                                                 Eligible: Student is majoring in one of the majors listed in CC Reg 145-1.

                                                          Waiver Required: Student is not majoring in one of the majors listed in CC Reg 145-1.                            Waiver Granted (Eligible):        Date

                                                          Ineligible (Waiver denied).


70. AGE                                                   Eligible: Student must be 17 years of age within the first semester following award of the scholarship (cannot contract until reaches age 17) and be under 31 years of age on 31 December
                                                                    of the calendar year of commissioning.
                                                          Ineligible (Statutory-Nonwaiverable): Student exceeds the statutory maximum age requirement IAW CC Reg 145-1.

71. ACADEMIC STATUS                                       Eligible: Student must meet ALL THREE of the following criteria: (a) Academically aligned. (b) Cumulative college GPA of 2.5 on a 4.0 scale, OR student has no college GPA yet, but
                                                                    has a cumulative high school GPA of 2.5 on a 4.0 scale. (c) Full time student (in accordance with university policy - usually 12 or more credit hours).
                                                                                                                  HS GPA                              OR                   College GPA
                                                          Waiver Required: (a) Student has a cumulative college GPA of less than 2.5 on a 4.0 scale. Rounding is not permitted. (b) Student has no cumulative college GPA yet, but has a cumulative
                                                                  high school GPA of less than 2.5 on a 4.0 scale. (c) Graduate student who is enrolled less than full time.
                                                                                                                                                           Waiver Granted (Eligible):        Date
                                                          Ineligible (Waiver denied or nonwaiverable).

72. ACT/SAT                                               Eligible: (a) Two-year scholarship recipient: no requirement (except two-year MJC). (b) Two-year MJC, three-year or four-year scholarship recipient with composite ACT score of 19 or
                                                                    greater OR composite SAT score of 920 or greater.
                                                                                                                 SCORE: SAT Verbal                              SAT Math                                 ACT Composite
                                                          Waiver Required: Two-year MJC, three-year or four-year scholarship recipient with composite ACT score of less than 19 OR composite SAT score of less than 920.
                                                                                                         SCORE: SAT Verbal                                  SAT Math                               ACT Composite

                                                                                                                                                             Waiver Granted (Eligible):        Date
                                                          Ineligible (Waiver denied or nonwaiverable): Two-year MJC, three-year or four-year scholarship applicant who has not taken the ACT or SAT.


73. ACADEMIC CREDITS                                      Eligible: At the time the scholarship begins, (a) Two-year scholarship recipients must have at least 4 semester/6 quarters remaining. (b) 2 1/2-year scholarship recipients must have at
                                                                    least 5 semester/7-8 quarters remaining. (c) Three-year scholarship recipients must have 6 semesters/9 quarters remaining, or (d) 3 1/2-year scholarship recipients must have
                                                                    7 semesters/10-11 quarters remaining.
                                                          Waiver Required: If the student does not meet the criteria above.                                  Waiver Granted (Eligible):        Date

                                                          Ineligible (Waiver denied).


74. PHYSICAL FITNESS                                      Eligible: Score of 180 with 60 points in each event on a single APFT. NOTE: All scholarship applicants must be given a physical assessment (APFT or PFT) during the face-to-face
                                                                    interview for assessment of physical ability. The APFT must be passed NLT 15 Dec (or NLT 1 May for mid-term entries) at the 60/60/60 - 180 standard prior to contracting.
                                                          Ineligible (Nonwaiverable): Failure to meet eligibility criteria.

                                                                                                              PART VIII - ENROLLMENT OFFICER CERTIFICATION
Certify by signature as many as applicable:
               BASIC COURSE: Student is eligible (fully or by waiver) for entry into the Basic Course.
                            Name/Rank:                                                                              Signature:                                                                                                   Date:


               NONSCHOLARSHIP: Student is eligible (fully or by waiver) to contract as a nonscholarship.
                            Name/Rank:                                                                              Signature:                                                                                                   Date:

               SCHOLARSHIP: Student is eligible (fully or by waiver) to contract as a scholarship recipient.

                            Name/Rank:                                                                              Signature:                                                                                                   Date:

CC Form 139-R, DEC 2007                                                                                                                                                                                                                               Page 5 of 6
                                                                                                                    CADET ENROLLMENT RECORD
                                                                                                                 Instructions and Notes (CC Pam 145-4)
The purpose of the Cadet Enrollment Record (CC Form 139-R) is threefold:
 1. To record necessary information for entering a Cadet into the CCIMS database.
 2. To create a legal record of Cadet enrollment.
 3. To guide the Enrollment Eligibility Officer through the process of determining eligibility for enrollment and contracting.
A student is not enrolled in Army ROTC until he/she has completed, signed, and initialed this form and the Enrollment Eligibility Officer certifies by signature that the student is eligible for
entry into the Basic Course. A Cadet will not be contracted until he/she has completed, signed, and initialed this form and the Enrollment Eligibility Officer certifies by signature that the
Cadet is eligible for contracting.
Contracting any student is subject to the approval of the PMS, even when all other eligibility criteria are met.
Cadre will verify that the information on this form is current and accurate during each required periodic counseling with the Cadet.

Reproduction of this form on cardstock for durability is recommended. You may fill in permanent information in ink and changeable items in pencil.
If a waiver is required, refer to the current "Approval Authority/Flow of Cadet Actions" matrix and CC Pam 145-4, or other published guidance for current processing of waivers.
This form will be retained in the Cadet's MPRJ as a permanent document and retained with the Cadet Record Brief for five years following the Cadet's appointment or disenrollment.

Notes and references:
Part I-III   Height and weight is approximate. Fully discuss with the student any physical conditions they identify in Part I.
Part IV      (a) Emphasize that the student is only signing that he/she has read and understands the Homosexual Conduct Policy Briefing. They are not making any statement about their sexual orientation by signing that statement.
                  Do not ask about a student's sexual orientation. (b) Signing the Loyalty Oath is optional for noncontracted students enrolling in the Basic Course. Aliens do not sign the Loyalty Oath.
Part V       Basic Course Enrollment Eligibility (Noncontracted Cadets): See notes/instructions for Part V.
             (1) Academic Status: AR 145-1, Ch 3; CC Pam 145-4.
             (2) Conscientious Objection: AR 145-1, Ch 3; CC Reg 145-1.
              (3) Character: AR 145-1, Ch 3; CC Pam 145-4.
              (4) Tattoos: AR 670-1, dtd 1 Jul 02, para 1-8e, TRADOC MSG dtd 011525Z, Subj: TRADOC/USAREC IET RECRUIT/CADET TATTOO/BRAND POLICY
              (5) Citizenship: Must be verified. The following documents may be used in verifying U.S. Citizenship: (a) Birth Certificate, (b) Certificate of Naturalization, (c) Certificate of Naturalization of parents, (d) INS From N-560
                   (Certificate of Citizenship, (e) Department of State Form 1350 (Certificate of Birth Abroad of a Citizen of the U.S.A.), (f) FS Form 240 (Report of Birth, Child Born Abroad of American Parent or Parents), (g) FS Form
                   545 (Certification of Birth Abroad of a Citizen of the U.S.A.), (h) Unexpired fully valid US Passport issued in the name of the applicant. AR 145-1, Ch 3; CC Reg 145-1 (for scholarship; CC Pam 145-4 (for processing aliens
                   for enrollment refer to AR 145-1, Ch 3, and CC Pam 145-4). Dual citizenship-foreign citizenship must be renounced prior to receipt of a clearance, which is a prerequisite for commissioning.
              (6) Medical: AR 145-1, Ch 3; CC Pam 145-4; AR 40-29; AR 40-501, Ch 2. Height and weight standards for prior service Cadets are found in AR 600-9. Height and weight standards for non-prior service Cadets are found
                   in AR 40-501 and CC Pam 145-4.
Part VI       Nonscholarship Contracting Eligibility: See notes/instructions for Part VI.
              (1) Basic Course Eligibility Requirements: Cadet must meet basic course eligibility requirements - (1) - (6).
              (2) Civil Conviction: AR 145-1, Ch3; CC Reg 145-1; CC Pam 145-4; and AR 601-210, Ch 4.
              (3) Dependency: AR 145-1, Ch 3; CC Pam 145-4. In questions of custody, only court orders are acceptable. Powers of Attorney have no binding legal effect in such cases. Cadre will not counsel or advise sole parent
                  applicants to turn over legal custody; they may only advise on eligibility standards IAW Army policy.
              (4) Substance Abuse: AR 145-1, Ch 3; CC Pam 145-4.
              (5) Loyalty Oath: Statutory: DoD Dir 1215.8; AR 145-1, Ch 3; CC Pam 145-4. Aliens specifically exempted by law.
              (6) Prior Service: AR 145-1, Ch 3; CC Reg 145-1; CC Pam 145-4; AR 601-210, Table 3-6 contains RE codes and their eligibility status.
              (7) Citizenship: Must be verified. The following documents may be used in verifying U.S. Citizenship: (a) Birth Certificate, (b) Certificate of Naturalization, (c) Certificate of Naturalization of parents, (d) INS From N-560
                   (Certificate of Citizenship, (e) Department of State Form 1350 (Certificate of Birth Abroad of a Citizen of the U.S.A.), (f) FS Form 240 (Report of Birth, Child Born Abroad of American Parent or Parents), (g) FS Form
                   545 (Certification of Birth Abroad of a Citizen of the U.S.A.), (h) Unexpired fully valid US Passport issued in the name of the applicant. AR 145-1, Ch 3; CC Reg 145-1 (for scholarship; CC Pam 145-4 (for processing aliens
                   for enrollment refer to AR 145-1, Ch 3, and CC Pam 145-4).
              (8) Placement Credit: AR 145-1, Ch 3; CC Reg 145-1.
              (9) Academic Alignment: CC Pam 145-4.
              (10) Physical Fitness: AR 145-1, Ch 3; CC Reg 145-1; Cc Pam 145-4; Cadet scholarship and non-scholarship contracts.
              (11) Medical: AR 145-1, Ch 3; Cc Pam 145-4; AR 40-29; AR 40-501, Ch 2. Height and weight standards for prior service Cadets are found in AR 600-9. Height and weight standards for non-prior service Cadets are found in
                   AR 40-501 and CC Pam 145-4. Female students who are pregnant are ineligible to contract, but regain eligibility at the end of the pregnancy. Pregnancy after enrollment is not a disqualifier.
              (12) Age: Statutory: AR 145-1, Ch 3; CC Reg 145-1; CC Pam 145-4.
Part VII      Scholarship Contracting Eligibility. See notes/instructions for Parts VI and VII.
              (1) Basic Contracting Eligibility Requirements: Cadet must meet basic contracting eligibility requirements in Part VI.
              (2) Medical: AR 145-1, Ch 3; Cc Pam 145-4; AR 40-29; AR 40-501, Ch 2. Height and weight standards for prior service Cadets are found in AR 600-9. Height and weight standards for non-prior service Cadets are found in
                   AR 40-501 and CC Pam 145-4. Female students who are pregnant are ineligible to contract, but regain eligibility at the end of the pregnancy. Pregnancy after enrollment is not a disqualifier.
              (3) Major: CC Reg 145-1, Appendix F.
              (4) Age: Statutory: AR 145-1, Ch 3; CC Reg 145-1.
              (5) GPA: CC Reg 145-1.
              (6) SAT/ACT: CC Reg 145-1.
              (7) Academic Credits: CC Reg 145-1.
              (8) Physical Fitness: AR 145-1, Ch 3; CC Reg 145-1; CC Pam 145-4; Cadet scholarship and non-scholarship contracts.




CC Form 139-R, DEC 2007                                                                                                                                                                                                                            Page 6 of 6
BRIEFING ON GOVERNMENT SPONSORED BENEFITS FOR ROTC CADETS
                                       (ROTC Cadet Cmd PAM 145-4)


I have been briefed this date on government-sponsored benefits for ROTC cadets
and understand that--

1. Enrolled ROTC cadets and applicants for enrollment who suffer illness/injury as a
result of authorized (scheduled and supervised) training, or authorized travel to and from
such training, are eligible for compensation through the Department of labor/Department
of Veteran Affairs.

2. ROTC cadets may not receive medical coverage and disability benefits from the
Department of Labor or the Department of Veteran Affairs for injuries sustained when
traveling off-post for personal recreation/activities. It is the responsibility of the
individual cadet to obtain adequate or additional insurance to cover themselves for off-
post, non-ROTC related activities.

3. ROTC cadets must report any injury/illness sustained while participating in authorized
training or authorized travel to and from such training to the battalion commander/PMS
or other authorized cadre. Cadets are responsible for submission of claims to the proper
department as listed in paragraph 1 above, with the assistance of battalion cadre.


4. Army medical treatment facilities (subject to the availability of space, facilities, and
capabilities of the professional staff) are authorized to provide care for injury incurred or
disease contracted while attending field training.

5. Injured students who are eligible to receive medical treatment are authorized medical
care from the following sources:

             a. U.S. Public Health Service hospitals or physicians where available.

              b. Army, Navy, Air Force, or VA medical treatment facilities, subject to the
availability of space, facilities, and the capabilities of the professional staff.



             DATE                                                        CADET SIGNATURE


                                                                              -
                                                                           Cadet Printed Name

CC FM 136-R, Aug 01
                    AUTHORIZATION/DECLINATION FOR ACCESS TO STUDENT RECORDS
                             For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PC


                                  DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority                20 USC 1232g, and Public Law 93-380
Principal Purpose        To authorize/decline the release of any and all official records maintained by the ROTC
                         Department to personnel in the Department of Defense and/or parents.
Routine Uses             To provide authorization/declination to release information contained in official records.
Disclosure               Disclosure is voluntary.


                        PART I - AUTHORIZATION FOR ACCESS TO STUDENT RECORDS


Having been advised of the provisions of Public Law 93-380 (20 USC 1232g, Family Educational Rights and
Privacy Act of 1974) and in connection with my participation in the Army ROTC program, I


                                      -                                              hereby authorize the release of any and
                        (Cadet's Name & UIN or SSN)


all official records maintained by the                                                           -
                                                                                         (Name of School)


or it's ROTC Department to personnel in the Department of Defense and/or my parents,

                                                             -                                                         .
                                                    (Name of Parents)


I waive any requirement that I be furnished a copy of those records prior to or concurrent with their
release. This consent remains effective until my relationship with the ROTC program is terminated.




Signature of Cadet                                                                                Date


                    PART II - DECLINATION OF PARENTAL ACCESS TO STUDENT RECORDS


Although informing my parents of the academic/ROTC progress made by me may assist in my quest to
become a commissioned officer, I decline to allow release of official records maintained by

                     University of Illinois at Urbana-Champaign                                      ROTC Department to my
                                     (Name of School)


parents. (Exception: Parents who still claim student as a dependent for IRS purposes) If I change my mind in the
future, I will inform the ROTC Department in writing.




Signature of Cadet                                                                                Date

CC FORM 137-R, AUG 02                                 PREVIOUS EDITIONS ARE OBSOLETE
             PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
        THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN)

           Sections 133, 1071-87, 3012, 5031 and 8012, title 10, United States Code and Executive Order 9397.



2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED

           This form provides you the advice required by The Privacy Act of 1974. The personal information will
           facilitate and document your health care. The Social Security Number (SSN) of member or sponsor is
           required to identify and retrieve health care records.



3. ROUTINE USES

           The primary use of this informaiton is to provide, plan and coordinate health care. As prior to enactment
           of the Privacy Act, other possible uses are to: Aid in preventive health and communicable disease control
           programs and report medical conditions required by law to federal, state and local agencies; compile
           statistical data; conduct research; teach; determine suitability of persons for service or assignments; adjudi-
           cate claims and determine benefits; other lawful purposes, including law enforcement and litigation; con-
           duct authorized investigations; evaluate care rendered; determine professional certification and hospital
           accreditation; provide physical qualifications of patients to agencies of federal, state, or local govern-
           ment upon request in the pursuit of their official duties.




4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION

           In the case of military personnel, the requested information is mandatory because of the need to document
           all active duty medical incidents in view of future rights and benefits. In the case of all other personnel/
           beneficiaries, the requested informaiton is voluntary. If the requested information is not furnished, compre-
           hensive health care may not be possible, but CARE WILL NOT BE DENIED.

           This all inclusive Privacy Act Statement will apply to all requests for personal information made by health
           care treatment personnel or for medical/dental treatment purposes and will become a permanent part of
           your health care record.

           Your signature merely acknowledges that you have been advised of the foregoing. If requested, a copy of
           this form will be furnished to you.



SIGNATURE OF PATIENT OR SPONSOR                      SSN OF MEMBER OR SPONSOR                                  DATE

                                                                    -

DD FORM 2005, FEB 76                                 PREVIOUS EDITION IS OBSOLETE
Please read through this form. You will sign it
          once you come to campus.
                Culture and Language Program
The Army is gathering info on cadets' level of foreign language and /or culture exposure.
Subsequently, all cadets commissioning after September 2008 must complete this form so we can submit
the data for our battalion.

Name:       -

Please read through each question, and place a checkmark in the box that applies to you.
1. Do you have bilingual capability?

                     Yes      (if yes, list languages below; add lines as needed to list all)
                     No

            Language                                        Are you fluent (native speaker/extensive training) or Limited
                 1
                 2
                 3

2. Have you lived (not studied abroad or visited) in a Foreign Country?                                      Yes
                                                                                                             No
            Country                                         Number of Months lived there
                 1
                 2
                 3

3. Have you studied abroad?

                     Yes      If yes, list country(ies) below: add lines as needed to flist all.
                     No

4. Did you study a foreign language in high school?

                     Yes      (If yes, list language(s) below)
                     No

            Language                Where terms semesters or quarters?                # of terms completed
                 1
                 2
                 3

5. Have you completed a Rosetta Stone Course?

                     Yes      (If yes, list courses below; add lines as needed to list all)
                     No

                     Course                         Level                                     Pass or Fail
                 1
                 2
                 3
PAGE 2        CULP          -

6. Have you studied a foreign language in college?

                      Yes   (If yes. list languages below; add lines as needed to list all)
                      No

              Language            Where terms semesters or quarters?               # of terms completed
                  1
                  2
                  3


7. Are you pursuing a degree in a Foreign Language in College?

                      Yes
                      No

              Language            Major or Minor
          1

          2
Read each question carefully and place an "X" in the box that
applies to you. Then type in the information requested.
                                           Medical Appointments
ALL ARMY ROTC Cadets MUST get a physical before participating in the lab portion (morning PT and Thu

You will be expected to complete your physical within one (1) week of completing enrollment paperwork.
(If attending COP/EMI, you may bring with you or scan and email signed, stamped and dated documents to a

You will also be expected to show up in civilian attire to labs and NOT participate until you have clearance fro

Everyone must fill out the Dental Record Request!

In order to participate in Army ROTC, you must schedule a sports physical. You can do this
1. McKinley Health Center (for UIUC students during the school year only) or,
2. Your personal Physician (for U of I or Parkland Students obtaining their physicals during the summer or Parkland
3. Convenient Care through Carle Clinic or Christie Clinic in the Champaign/Urbana area (see "If you do not have a
      physical or,
4. Your local Convenient Care facility if you don't have a doctor.


FOR COP/EMI ONLY: Print the Dental Record Req., Med. Auth. - Non-McKinley Appt, Med History-Non-M
Physical Exam-Non-McKinley Appt, DA 3425 (Please read through the Med. Appointment Non-McKiney)


If you are applying during the school year, print the forms that pertain to your college/university - Parkland S
forms and U of I will print up the "UIUC" forms.


Before you go to the medical appointment however, you must complete your Medical History (DD 2492). Please t
If you are going to your family doctor, please have the doctor verify all the "Yes" answers and provide information in
For "yes" answers, please provide all documentation from your doctor.
If you are going to a convenient care facility, please try to verify any "yes" answers through whoever has your official

Once the physician has finished your exam, please have him fill out the Physical Exam, the Medical Fitness Statemen
an explanation to us for all "yes" answers. Please ensure all forms have the doctor's signature, printed name, their off


If you do not have a doctor:
You may go to the Carle Clinic Convenient care closest to you: http://www.carle-clinic.com/Convenient_Care/Pages
or Chrstie Clinic Convenient Care: http://www.christieclinic.com/primary-care-and-specialties/specialty/260/conveni
or a Convenient Care near your hometown.


You MUST have the doctor's signature, printed name, and their office address and phone number e
the physical forms or have the doctor write in his/her office address and phone number on the forms
(morning PT and Thursday afternoon lab) of Army ROTC.

ment paperwork.
 dated documents to arotc@illinois.edu)

you have clearance from your ROTC Advisor.




l. You can do this either through:

he summer or Parkland College Students (anytime during the year)),
e "If you do not have a doctor:" below) to obtain a sports




t, Med History-Non-McKinley Appt,
ment Non-McKiney)


niversity - Parkland Student will print up the "Non-McKinley"




ry (DD 2492). Please take the completed form with you to your exam,
 provide information in space 85 where the doctor should comment.

hoever has your official medical records.

edical Fitness Statement and confirm all "yes" statements on the Medical History by providing
 printed name, their officce address and phone number either stamped or written on the forms.




Convenient_Care/Pages/Locations.aspx
s/specialty/260/convenient-care/



nd phone number either stamped on
number on the forms so that the physical can be valid.
                                              DEP AR T M ENT OF T H E ARM Y
                                            UNITED STATES ARMY ROTC BATTALION
                                          UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN
                                               505 E. ARMORY STREET, ROOM 113E
                                                 CHAMPAIGN, ILLINOIS 61820 -6250                                Please prin
                                                                                                                and return t
                   REPLY TO
                   ATTENTION OF:




ATC-CCI-LUI


MEMORANDUM FOR Record

SUBJECT: Dental Record Requirements


1. The following information is taken from Cadet Command Pam 145-5, para 2-55b, dated 7 Nov 05:

     b. Dental films for casualty identification purposes are required for all participants in the ROTC
program who must use government-owned or government contracted transportation. The PMS is to ensure
the Cadet’s dental records contain sufficient documentation to aid in forensic identification.

        (1) ROTC Cadets must provide name, address, and phone number of his/her dentist and sign a
statement acknowledging that his/her civilian dental records contain descriptive profiles, bitewing x-rays,
orthodontic profiles or dental x-rays.

         (2) ROTC Students not pursuing commissioning credit (ineligibles, academic credit only, etc.)
are not permitted to participate in other than classroom activities. However, if these students are
transported using government owned or government contracted transportation, they must have a dental
record for identification purposes. In such circumstance, these students must provide the name, address,
and phone number of his/her dentist and sign a statement acknowledging this his/her civilian dental records
contain descriptive profiles, bite wing x-rays, orthodontic profiles, or dental x-rays.

    c. In addition to the above, DNA is obtained as part of the commissioning physical at LDAC.



Cadet Name:                                                                SSN:

Name of Dentist:

Dentist Address:



Dentist Phone:

“I acknowledge that my dental records contain descriptive profiles, bite wing x-rays, orthodontic profiles or
dental x-rays.”



Cadet Signature                                                          Date
 nt this form and fill out, scan and email
n to arotc@illinois.edu
    Medical Appointment U of I
        You may call McKinley Health Center (217-333-2700) or go on-line to make your appt. at
http://www.mckinley.illinois.edu/general/appointments.htm. You may be able to do this on a
walk-in basis, but it is always best to schedule your appointment first.


Take the Medical Fitness Statement (DA 3425-R) and the Authorization For Disclosure of
Confidential Health Care Information to McKinley Health Center (1109 South Lincoln Avenue,
Urbana, IL). They will give you a sport physical and you can either pick up the physical and
bring it to our offices, or they can mail it to our offices. They should give you the forms we
requested on the Authorization Sheet. It is important that we get those forms along with your
physical.


**NOTE: If you are applying for or have received a Federal
Scholarship and are NOT DODMERB QUALIFIED, you MUST
have a physical before you participate in the Lab portion of Army
ROTC. And you must have a passing grade in the Lab portion of
Army ROTC to maintain your scholarship.
                                                                                                                              place label here
  *450*
  *450*
                                                                                                                              Name:
                                                                                                                              UIN:
                                                                                                                              Date:
                                           Medical Records Department
                                           1109 South Lincoln Avenue
                                           Urbana, IL 61801
                                           Phone (217) 333-2720 Fax (217) 244-6495

                AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL HEALTH CARE INFORMATION

                Name (Please Print)                                                        -                                          UIN                 -

                   Date of Birth                  -         Current Phone No                              -                 Date of Request

                 I authorize McKinley Health Center to release / receive (circle one) information from my patient records as described below (specify who records
                will be sent to or received from):

              Agency/Facility/Person       Department of Military Science
       Address                             113W Armory Building, MC-526
City, State, Zip                           Champaign, IL 61820-6250
       *Phone #                            (217) 244-1407                          *Fax #                          217-244-1406        *For Health Care Facility Fax Use Only

                Specific Records to be Disclosed:
                                             X Immunization Records                          Clinic Notes              X Laboratory Reports
                  X-ray Reports              X-ray Films                                   Allergy records           X Physical Exam              Verbal Communication
                  Other: Specify

                Approximate date(s) of treatment:

                Purpose of Disclosure:                             Continuing medical treatment                                   X School admission requirements
                       Volunteer Work                              Other

      By checking the box or boxes below, you are authorizing the release of the following information:
                 HIV/AIDS (as defined by Illinois Statute) – will not be released unless specifically indicated.
                 Alcohol and/or drug abuse treatment information protected under the regulations in 42 Code of Federal Regulations –
                     will not be released unless specifically indicated.
                 Mental Health records (as defined by Illinois Mental Health and Developmental Disabilities Confidentiality Act) –
                     will not be released unless specifically indicated.

  I UNDERSTAND THE FOLLOWING PROVISIONS:

                     I have the right to inspect and receive copies of information to be disclosed.
                     I have the right to revoke this consent at any time.
                     Revoking this consent shall have no effect on disclosures made before the revocation of consent.
                     Any revocation of consent must be submitted in writing to the Medical Records Unit and signed by the person who gave the consent.
                     The confidential information disclosed and used pursuant to this Authorization may be subject to redisclosure by the recipient and no longer protected by law .**
                     The confidential information disclosed and used pursuant to this Authorization may be subject to redisclosure by the recipient and no longer protected by law .**
                      It has been explained to me that if I refuse to consent to this disclosure of information, the following are the consequences:

                                                                  You will be unable to participate in PT for Army ROTC
                      This authorization expires 90 calendar days after it is signed or upon the following specific date, event or condition:




                  Signature of Patient or Consenting Individual                                                                                  Date

                   If signature is not of Patient, indicate relationship
                   Signature of Witness                                                                                                            Date

   **NOTICE TO RECEIVING AGENCY/FACILITY/PERSON: Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, you may not redisclose any
                          records disclosed pursuant to said Act unless the person who consented to this disclosure specifically consents to such redisclosure.

       For Office Use Only          □ Mail     □ Pick-up (date ________)       □ Fax        □ RUSH            Appt Date________________

       -RECORDS COMPLETED:
                 Method: 1) Mailed, 2) Hand Carried, 3) Faxed, 4) Messenger, 5) X-ray films hand carried, 6) Reviewed records
     # pages               Date               Method                  Init                      # pages              Date         Method           Init        # pages          Date      Method   Init



                                                                                                                                    8/17/05:bah     HIPAA rev/rev 11/2004:dlc
                                   DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)                                                                                         Form Approved
                                             REPORT OF MEDICAL HISTORY                                                                                                    OMB No. 0704-0396
               (This information is for official and medically confidential use only and will not be released to unauthorized persons.)                                   Expires Sep 30, 2006

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaing 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 includintg suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0396). 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 currently valid OMB control
number.




PLEASE RETURN THE FORM TO: Army ROTC Battalion, University of Illinois at Urbana-Champaign, 505 E. Armory Avenue, Room 113W,
Champaign, IL 61820-6250
                                                                              PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy,
Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the
Social Security Number (SSN) is used for positive identification of records.
1. NAME (Last, First, Middle Initial)       (FICE: 001775)                                    2. SOCIAL SECURITY NUMBER                      3. TELEPHONE NO. (Include area code)


4. PURPOSE OF EXAMINATION                         5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)                                                   6. DATE OF EXAMINATION
                                                                                                                                                                          (YYYYMMDD)
Entrance Physical (Army ROTC)


SECTION I
  Mark each item "Yes" or "No". Every question must be answered. Every "Yes" must be explained in the REMARKS section. Mark and
explain each item to the best of your ability. Be perfectly honest! Your medical records may be requested to clarify your medical history.
7. HAVE YOU EVER OR DO                      YES NO                                YES NO DO YOU                                         9a. If you wear contact lenses, how many days have they
YOU NOW USE ANY OF                                    Marijuana                               8. Wear glasses                           been removed prior to this examination?
YES NO THE FOLLOWING:                                 Alcohol (Amount                         9. Wear contact lenses or                   Less than 3                    3-20              21 or over
             Amphetamines                             frequency, treatment                    corneal eye retainers
                                                                                                                                              Type lens:                 Hard                   Soft
             Barbiturates                             if any)                                 (If Yes, complete 9a.)
             Cocaine                                  Chemical Inhalants                      10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED
             Narcotic Drugs                           Hallucinogens                           IN QUESTIONS 8 OR 9?
YES NO HAVE YOU EVER HAD OR DO YOU NOW HAVE:                          YES NO                                                            YES NO
             11. Eye trouble (exclude glasses, contact lenses)                    40. Gallbladder trouble or gallstones                            66. Sleepwalking episodes after age 12
             12. Have fluctuating vision or double vision                         41. Hepatitis (yellow jaundice)                                  67. Easily fatigued
             13. Have any allergies                                               42. Hemorrhoids or rectal disease                                68. Motion sickness (car, train, sea, or air)
             14. Take any medications regularly                                   43. Black or bloody stools                                       69. X-ray or other radiation therapy
             15. Stutter or stammer                                               44. Frequent or painful urination                                70. Sensitivity to chemicals, dust, sunlight, etc.
             16. Frequent, severe, or migraine headaches                          45. Bed wetting after age 12                                     71. Learning disabilities or speech problems
             17. Fainting or dizzy spells                                         46. Blood, protein, or sugar in urine                 YES NO HAVE YOU EVER
             18. Periods of unconsciousness                                       47. History of diabetes                                          72. Been refused employment or been unable to
             19. Head injury or skull fracture                                    48. Kidney stone                                                 hold a job or stay in school because of:
             20. Epilepsy, seizures or convulsions                                49. Hernia or rupture                                                 a. Inability to perform certain movements?
             21. Loss of memory (amnesia)                                                                                                               b. Inability to assume certain positions?
                                                                                  50. Any bone or joint problem, injuries, surgery or
             22. Depression, anxiety, excessive worry, or                         medical treatment                                                     c. Other medical reasons?
                nervousness                                                                                                                        73. Been rejected for or discharged from military
                                                                                  51. Steel pins, plates, or staples in any bones
                                                                                                                                                   service because of physical, mental or other
             23. Any mental condition or illness                                  52. Wear a bone or joint brace or support                        reasons?
             24. Frequent trouble sleeping                                        53. Back pain or trouble                                         74. Been denied or rated up for life insurance?
             25. Hearing loss                                                     54. Paralysis or weakness                                        75. Received or applied for pension or
             26. Ear, nose, or throat trouble                                     55. Foot trouble/use orthotics                                        compensation for existing disability?
             27. Sinusitis or sinus trouble                                       56. Rheumatic fever                                              76. Had or been advised to have, any surgical
             28. Hay fever or allergic rhinitis                                   57. Tuberculosis or positive TB test                                  operations?
             29. Tooth/gum trouble, or current orthodontics                       58. Sexually transmitted disease (syphilis,                      77. Consulted, or been treated by clinics,
                                                                                     gonorrhea, herpes)                                               hospitals, physicians, healers, or other
             30. Thyroid trouble
                                                                                                                                                      practitioners for other than minor illnesses?
             31. Chronic cough or lung disease                                    59. Skin conditions such as acne, psoriasis,                     78. Had any injury or illness other than those
             32. Asthma or wheezing                                                  hand or foot rashes, eczema, or dry skin                           already noted?
             33. Unusual shortness of breath                                      60. Adverse reaction to vaccines, drugs,              YES NO     FEMALES ONLY (Complete Items 79 - 82)
             34. Pain or pressure in chest                                           medicines, foods, insect bites or stings                      79. Been treated for a female disorder, painful
      35. Palpitation or pounding heart              61. Eating disorder                             periods, or cramps
      36. Heart trouble or heart murmur              62. Recent gain or loss of weight            80. Had a change in menstrual pattern
      37. High blood pressure                        63. Excessive bleeding or easy bruising      81. Are you now pregnant?
      38. Coughed up or vomited blood                64. Tumor, growth, cyst, or cancer           82. Date of last menstrual period (YYYYMMDD)
      39. Stomach, liver, or intestinal trouble      65. Considered or attempted suicide
DD FORM 2492, MAR 2004                            PREVIOUS EDITION IS OBSOLETE.                DoD Exception to SF93 approved by GSA/IRMS (8-91)
SECTION II
83. REMARKS. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and details
   including names of physicians and hospitals or clinics and the current status of the condition. If possible, obtain your medical records from your
   physician for any "yes"answers. Continue on a separate sheet and attachto this form if additional space is needed.




84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my
knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my
medical record for purposes of processing my application for this employment or service.
TYPED OR PRINTED NAME OF EXAMINEE SIGNATURE                                               SIGNATURE                                                            DATE SIGNED
                                                                                                                                                               (YYYYMMDD)


NOTE: HAND TO THE PHYSICIAN OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."
85. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Examiner shall comment on all "Yes" and blank answers (indicating the item number
before each comment). Develop by interview any additional medical history deemed important, and record significant findings here. If additional space is needed,
continue on a separate sheet and attach to this form.)




86. PHYSICIAN OR EXAMINER                                                                                                                                      87. NUMBER OF
TYPED OR PRINTED NAME DATE SIGNED                                 SIGNATURE                                                      DATE SIGNED                       ATTACHED
                                                                                                                                        (YYYYMMDD)                 SHEETS


DD FORM 2492 (BACK), MAR 2004
                            MEDICAL FITNESS STATEMENT                                        DATE
               FOR ENROLLMENT IN BASIC COURSE, SENIOR ROTC
                For use of this form, see AR 145-1, the proponent agency is ODSCPER




                   I have examined                                     -                     and find no medical
condition or physical impairment that precludes his/her participation in the basic course, Army ROTC, a
program not more physically strenuous than a normal college physical education program.




SIGNATURE and PRINTED NAME OF PHYSICIAN


                                                                                                                                       USAPPC V1.00
DA FORM 3425-R, 1 SEP 68


                                           (Ref CCP 145-4, para 2-32g, 2-32(a) and 2-34(a)

A medical examination for Basic Course applicants (MS I and MS II) must be withint one (1) year prior to enrollment.

Cadets are responsible for maintaining a high degree of physical fitness and must notify a cadre membr if ill or injured.

Cadets are responsible for furnishing the prescribed statement as to their physical capability to participate in the ROTC program.
This statement will be made by a physician using the Medical Fitness Statement or institutional medical records in lieu of the completed
form. Any expense incidental to such a medical examination will be borne by applicant.

For continues enrollment in the ROTC program, applicants must be physically capable of participation. The "medical exam will be of
sufficient scope to permit the examiner to state without qualification that the individual's health and well being will not be compromised
by participation in the ROTC program, i.e., a program not more physically strenuous than a normal college physical education program."

Your personal physician may complete this form, using his medical records as reference. You may go to McKinley Health Center,
but before they sign the form, they will give you a physical. That will count as one of the few physicals you can receive free of charge
from them (U of I students). If you do not keep the appointment, you will more than likely be charged for a missed appointment.
PARKLAND COLLEGE OR NON-MCKINLEY PHYSICAL
INSTRUCTIONS:


If you are a Parkland College Student or are having your personal Physician or you will go
to a Convenient Care to have your physical:
        You must take the Medical Fitness Statement form (DA 3245-R), the Med. Auth. – Non-
McKinley, Med History Non-McKinley Appt, Physical Exam-Non-McKinley Appt – to your
doctor and receive a sports physical. If you do not have a doctor, you may go to the Carle Clinic
Convenient care closest to you: http://www.carle-
clinic.com/Convenient_Care/Pages/Locations.aspx or Chrstie Clinic Convenient Care:
http://www.christieclinic.com/primary-care-and-specialties/specialty/260/convenient-care/
or a Convenient Care near your hometown. You MUST have the doctor sign, stamp with his
address and phone number or have the doctor write in his/her address and phone number so that
the physical can be valid.
       You will be responsible for paying for this physical out of pocket.
       If you have any problems or concerns, please contact us at 217-244-1407 or come by the
Scholarships and Enrollment Office at room 113W Armory Building.


**NOTE: If you are applying for or have received a Federal
Scholarship and are NOT DODMERB QUALIFIED, you MUST
have a physical before you participate in the Lab portion of Army
ROTC. And you must have a passing grade in the Lab portion of
Army ROTC to maintain your scholarship.
                                                           Army ROTC Battalion
                                                 University of Illinois at Urbana-Champaign
                                                    505 E. Armory Avenue, Room 113W
                                                         Champaign, IL 61820-6250
         AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL HEALTH CARE INFORMATION
 Name (Please Print)
     Address:
     Date of Birth                       Current Phone No                                               Date of Request
 I authorize my physician to release information from my patient records as described below (specify who records
  will be sent to):
     Agency/Facility/Person              Army ROTC Battalion, University of Illinois at Urbana-Champaign
     Address                             505 E. Armory Avenue, Room 113W
     City, State, Zip                    Champaign, IL 61820-6250
     *Phone #       (217) 244-1407                  *Fax #               217-244-1406                *For Health Care Facility Fax Use Only
 Specific Records to be Disclosed: X Immunization Records                               X Clinic Notes            X Laboratory Reports
  X X-ray Reports  X-ray Films X Allergy records                                        X Physical Exam            Verbal Communication
      Other: Specify
 Approximate date(s) of treatment:

 Purpose of Disclosure:                  Continuing medical treatment                       X School admission requirements
   Volunteer Work                        Other
 By checking the box or boxes below, you are authorizing the release of the following information:
      HIV/AIDS (as defined by Illinois Statute) – will not be released unless specifically indicated.
      Alcohol and/or drug abuse treatment information protected under the regulations in 42 Code of Federal Regulations –
       will not be released unless specifically indicated.
      Mental Health records (as defined by Illinois Mental Health and Developmental Disabilities Confidentiality Act) –
       will not be released unless specifically indicated.
 I UNDERSTAND THE FOLLOWING PROVISIONS:
         I have the right to inspect and receive copies of information to be disclosed.
         I have the right to revoke this consent at any time.
         Revoking this consent shall have no effect on disclosures made before the revocation of consent.
         Any revocation of consent must be submitted in writing to your doctor’s office and signed by the person who gave the consent.
         The confidential information disclosed and used pursuant to this Authorization may be subject to redisclosure by the recipient and no
          longer protected by law.**
         It has been explained to me that if I refuse to consent to this disclosure of information, the following are the consequences:
                                          You will NOT be able to participate in PT for Army ROTC                                  (specify if any)
         This authorization expires 90 calendar days after it is signed or upon the following specific date, event or condition:



 Signature of Patient or Consenting Individual                                                                         Date
  (If Patient is not 18 years old, parent or guardian must sign)

     If signature is not of Patient, indicate relationship


     Signature of Witness                                                                                               Date
**NOTICE TO RECEIVING AGENCY/FACILITY/PERSON: Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality
  Act, you may not redisclose any records disclosed pursuant to said Act unless the person who consented to this disclosure specifically consents to such
  redisclosure.
                                                                                                               8/17/05:bah     HIPAA rev/rev 11/2004:dlc
Print the form. Fill out the Name, Address, Date of Birth lines. Go
to the bottom - date and sign the form. If you are under 18 have
your parents sign and date the form for you and below state the
relationship the person signing has to you.
You can type on the form and print but you must click in the middle
two times because the form is a word document embedded into an
excel spreadsheet. You may then proceed to fill it out on the
computer. When you are finished, click outside the embedded
object and you should be able to print. Do not worry that some of
the form doesn't show - that's normal. Questions? Give me a call
217-244-1407.
                                   DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)                                                                                         Form Approved
                                             REPORT OF MEDICAL HISTORY                                                                                                    OMB No. 0704-0396
               (This information is for official and medically confidential use only and will not be released to unauthorized persons.)                                   Expires Sep 30, 2006

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaing 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 includintg suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0396). 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 currently valid OMB control
number.
PLEASE RETURN THE FORM TO: Army ROTC Battalion, University of Illinois at Urbana-Champaign, 505 E. Armory Avenue, Room 113W,
Champaign, IL 61820-6250
                                                                                PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy,
Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the
Social Security Number (SSN) is used for positive identification of records.
1. NAME (Last, First, Middle Initial)       (FICE: 001775)                                    2. SOCIAL SECURITY NUMBER                      3. TELEPHONE NO. (Include area code)


4. PURPOSE OF EXAMINATION                         5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code)                                                   6. DATE OF EXAMINATION
                                                                                                                                                                          (YYYYMMDD)
Entrance Physical (Army ROTC)


SECTION I
  Mark each item "Yes" or "No". Every question must be answered. Every "Yes" must be explained in the REMARKS section. Mark and
explain each item to the best of your ability. Be perfectly honest! Your medical records may be requested to clarify your medical history.
7. HAVE YOU EVER OR DO                      YES NO                                YES NO DO YOU                                         9a. If you wear contact lenses, how many days have they
YOU NOW USE ANY OF                                       Marijuana                            8. Wear glasses                           been removed prior to this examination?
YES NO THE FOLLOWING:                                    Alcohol (Amount                      9. Wear contact lenses or                   Less than 3                    3-20              21 or over
             Amphetamines                                frequency, treatment                 corneal eye retainers
                                                                                                                                              Type lens:                 Hard                   Soft
             Barbiturates                                if any)                              (If Yes, complete 9a.)
             Cocaine                                     Chemical Inhalants                   10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED
             Narcotic Drugs                              Hallucinogens                        IN QUESTIONS 8 OR 9?
YES NO HAVE YOU EVER HAD OR DO YOU NOW HAVE:                             YES NO                                                         YES NO
             11. Eye trouble (exclude glasses, contact lenses)                    40. Gallbladder trouble or gallstones                            66. Sleepwalking episodes after age 12
             12. Have fluctuating vision or double vision                         41. Hepatitis (yellow jaundice)                                  67. Easily fatigued
             13. Have any allergies                                               42. Hemorrhoids or rectal disease                                68. Motion sickness (car, train, sea, or air)
             14. Take any medications regularly                                   43. Black or bloody stools                                       69. X-ray or other radiation therapy
             15. Stutter or stammer                                               44. Frequent or painful urination                                70. Sensitivity to chemicals, dust, sunlight, etc.
             16. Frequent, severe, or migraine headaches                          45. Bed wetting after age 12                                     71. Learning disabilities or speech problems
             17. Fainting or dizzy spells                                         46. Blood, protein, or sugar in urine                 YES NO HAVE YOU EVER
             18. Periods of unconsciousness                                       47. History of diabetes                                          72. Been refused employment or been unable to
             19. Head injury or skull fracture                                    48. Kidney stone                                                 hold a job or stay in school because of:
             20. Epilepsy, seizures or convulsions                                49. Hernia or rupture                                                 a. Inability to perform certain movements?
             21. Loss of memory (amnesia)                                                                                                               b. Inability to assume certain positions?
                                                                                  50. Any bone or joint problem, injuries, surgery or
             22. Depression, anxiety, excessive worry, or                         medical treatment                                                     c. Other medical reasons?
                nervousness                                                                                                                        73. Been rejected for or discharged from military
                                                                                  51. Steel pins, plates, or staples in any bones
                                                                                                                                                   service because of physical, mental or other
             23. Any mental condition or illness                                  52. Wear a bone or joint brace or support                        reasons?
             24. Frequent trouble sleeping                                        53. Back pain or trouble                                         74. Been denied or rated up for life insurance?
             25. Hearing loss                                                     54. Paralysis or weakness                                        75. Received or applied for pension or
             26. Ear, nose, or throat trouble                                     55. Foot trouble/use orthotics                                        compensation for existing disability?
             27. Sinusitis or sinus trouble                                       56. Rheumatic fever                                              76. Had or been advised to have, any surgical
             28. Hay fever or allergic rhinitis                                   57. Tuberculosis or positive TB test                                  operations?
             29. Tooth/gum trouble, or current orthodontics                       58. Sexually transmitted disease (syphilis,                      77. Consulted, or been treated by clinics,
                                                                                     gonorrhea, herpes)                                               hospitals, physicians, healers, or other
             30. Thyroid trouble
                                                                                                                                                      practitioners for other than minor illnesses?
             31. Chronic cough or lung disease                                    59. Skin conditions such as acne, psoriasis,                     78. Had any injury or illness other than those
             32. Asthma or wheezing                                                  hand or foot rashes, eczema, or dry skin                           already noted?
             33. Unusual shortness of breath                                      60. Adverse reaction to vaccines, drugs,              YES NO     FEMALES ONLY (Complete Items 79 - 82)
             34. Pain or pressure in chest                                           medicines, foods, insect bites or stings                      79. Been treated for a female disorder, painful
             35. Palpitation or pounding heart                                    61. Eating disorder                                                   periods, or cramps
             36. Heart trouble or heart murmur                                    62. Recent gain or loss of weight                                80. Had a change in menstrual pattern
             37. High blood pressure                                              63. Excessive bleeding or easy bruising                          81. Are you now pregnant?
             38. Coughed up or vomited blood                                      64. Tumor, growth, cyst, or cancer                               82. Date of last menstrual period (YYYYMMDD)
             39. Stomach, liver, or intestinal trouble                            65. Considered or attempted suicide
DD FORM 2492, MAR 2004   PREVIOUS EDITION IS OBSOLETE.   DoD Exception to SF93 approved by GSA/IRMS (8-91)
SECTION II
83. REMARKS. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and details
   including names of physicians and hospitals or clinics and the current status of the condition. If possible, obtain your medical records from your
   physician for any "yes"answers. Continue on a separate sheet and attachto this form if additional space is needed.




84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my
knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my
medical record for purposes of processing my application for this employment or service.
TYPED OR PRINTED NAME OF EXAMINEE SIGNATURE                                               SIGNATURE                                                            DATE SIGNED
                                                                                                                                                               (YYYYMMDD)


NOTE: HAND TO THE PHYSICIAN OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."
85. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Examiner shall comment on all "Yes" and blank answers (indicating the item number
before each comment). Develop by interview any additional medical history deemed important, and record significant findings here. If additional space is needed,
continue on a separate sheet and attach to this form.)




86. PHYSICIAN OR EXAMINER                                                                                                                                      87. NUMBER OF
TYPED OR PRINTED NAME DATE SIGNED                                 SIGNATURE                                                      DATE SIGNED                       ATTACHED
                                                                                                                                        (YYYYMMDD)                 SHEETS


DD FORM 2492 (BACK), MAR 2004
This form must be printed and taken to your family
doctor. The doctor will give you a physical exam and
then will fill out the form form. Your doctor can send it to
us along with the Medical Authorization, Medical History,
DA 3425 and any notes, paperwork that pertains to any
illnesses, problems you may have had in your lifetime.
You can hand carry the completed form from your
doctor to COP or scan and email it to us in time for the
Cadet Orientation Program. Email is arotc@illinois.edu.
Your doctor can fax all completed medical forms to us at
217-244-1406.
                            MEDICAL FITNESS STATEMENT                                        DATE
               FOR ENROLLMENT IN BASIC COURSE, SENIOR ROTC
                For use of this form, see AR 145-1, the proponent agency is ODSCPER




                   I have examined                                     -                     and find no medical
condition or physical impairment that precludes his/her participation in the basic course, Army ROTC, a
program not more physically strenuous than a normal college physical education program.




SIGNATURE and PRINTED NAME OF PHYSICIAN


                                                                                                                                       USAPPC V1.00
DA FORM 3425-R, 1 SEP 68


                                           (Ref CCP 145-4, para 2-32g, 2-32(a) and 2-34(a)

A medical examination for Basic Course applicants (MS I and MS II) must be withint one (1) year prior to enrollment.

Cadets are responsible for maintaining a high degree of physical fitness and must notify a cadre membr if ill or injured.

Cadets are responsible for furnishing the prescribed statement as to their physical capability to participate in the ROTC program.
This statement will be made by a physician using the Medical Fitness Statement or institutional medical records in lieu of the completed
form. Any expense incidental to such a medical examination will be borne by applicant.

For continues enrollment in the ROTC program, applicants must be physically capable of participation. The "medical exam will be of
sufficient scope to permit the examiner to state without qualification that the individual's health and well being will not be compromised
by participation in the ROTC program, i.e., a program not more physically strenuous than a normal college physical education program."

Your personal physician may complete this form, using his medical records as reference. You may go to McKinley Health Center,
but before they sign the form, they will give you a physical. That will count as one of the few physicals you can receive free of charge
from them (U of I students). If you do not keep the appointment, you will more than likely be charged for a missed appointment.
FACILITIES & SERVICES - MILITARY STORES UNIFORM APPLICATION

PLEASE PRINT ALL INFORMATION

All uniforms & equipment issued to students/cadets are loaned without a cash deposit. The University is required by the State
Comptroller, to collect a Social Security number when extending credit. If your account becomes delinquent, your Social
Security number will be provided to the state or to a private collection agency to assist in the settlement of the debt/recovery
of the property. Providing a Social Security number is voluntary, if you do not wish to provide your number, you
will be required to pay a cash deposit. Fill out all highlighted areas of this form.

Sex ( circle) MALE/ FEMALE                                                         Social Security #                               -

UIN (on I-card)                                                  -

ID Card # (16 digits)                                            -                          Net ID                                 -
(On bottom of I-Card across from UIN)

Name (last,first, middle)                                                                          -

Local Address                                              -                                           -                  -                  -
                                                       Street                               City                     State             Zip
Local Phone

Home Address                                               -                               -                         -                 -
                                                       Street                              City                      State             Zip
Home Phone                                                  -

Circle one
US Citizen                              Yes            No

Circle all that apply:
U of I Student                          Parkland Jr. College Student            National Guard Member*               Reserve Member*

I understand I am assuming full responsibility for safekeeping and cleaning of all items issued to me from Military
Stores. I further agree to return all items when I am no longer involved with ROTC or when told to do so.
I understand I will be held financially responsible for items damaged, and/or not returned.

SIGNATURE______________________________________________________________


*In a Guard/Reserve Unit? You must get issued your uniform from your unit. The only items we will issue you are Class A coat, garrison cap, rank and
if needed, a PT belt. Everything else MUST come from your unit. If your unit will not issue you a uniform, you MUST PRESENT TO US your issue list
along with your unit's name, telephone number and point of contact for your uniforms.
                                                                                                                               28-Jul-2009
Name:                                                           Mission Set (when you will
                                                                 commission)
What is your Major?

How did you hear about us?
        Internet
        Campus Orientation
        Guidance Counselor/HS Visit
        Friend/Family member
        National Guard/Reserve Unit
        Other (please explain)

Why did you join Army ROTC?
        Financial Incentives
        Needed Sense of Direction
        Family/Peer Pressure
        Something Different
        Family Tradition
        Sense of Patriotism/Duty/Selfless Service
        Other (please explain)

Did you have a Scholarship? Y/N
         Federal       year
         State Tuition Waiver
         Nursing
         National Guard Grant
         Other (please explain)

What High School did you attend? (please include city, state)


Would you recommend us to a friend/sibling? (please explain if no)


What other University activities (if any) do you participate in (RSOs, Frat/Sorority, etc.)?




What are some of your hobbies (brief bio portion)?
                              GENERAL RELEASE
                         (Participation without remuneration)


The United States Government has request me to grant, release, and discharge to it certain rights
(hereinafter more fully set forth) arising from my participation in a particular production (be it
motion picture film, telecast, television recording, filmstrip or photograph) to be made by or
produced for the United States Government.

This grant, release, and discharge of said rights to the United States Government is made freely
and without exception of recompense of any kind, in full cognizance of the risks inherent in the
operational techniques employed in the production, including but not limited to, the focusing of
lights upon me: and in contemplation of the reliance by the United States Government upon the
rights herein granted and released.

I hereby grant and release to the United States Government the following rights:

    a. To use my name, photograph, likeness, acts poses, plays, and appearances made in
       connection with the said production in any manner; to record, reproduce, amplify,
       simulate, filter or otherwise distort my voice and all instrumental, musical, and other
       sound effects produced by me: and to reproduce, duplicate, publish, exhibit, use or
       transmit the same or any parts thereof, by any means, in any manner and for any purpose
       whatsoever, and to use the same perpetually.
    b. The right to “double” or “dub” my voice, acts poses, plays, and appearances, and all
       instrumental, musical and/or other sound effects produced by me to such extent as may
       be desired by the United States Government.
    c. The release and discharge of the United States Government from any cause of action of
       whatsoever nature arising from my participation in the production. This voluntary grant
       and release will not be made the basis of a future claim of any kind against the
       Government.

    This grant, release, and discharge shall ensure to the benefit of the United States
    Government, and its officers, agents, servants, and employees when acting in their official
    capacities: and to persons, firms, on corporations contracting with the Government and their
    heirs, executors, administrators, successors, or assigns; and to any other persons lawfully
    reproducing, distributing, exhibiting, or otherwise using the said production of any portion
    thereof.




                     Signature                                    Typed Name




                                                 Date
Planned Academic Worksheet

For COP/EMI - Please do NOT fill out this form at this time


For all other times during the year, we will send you an email.
                                                                                 PLANNED ACADEMIC PROGRAM WORKSHEET
                                                                       For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PA-C
                                                                           DATA REQUIRED BY PRIVACY ACT STATEMENT OF 1974
1. AUTHORITY: Title 10, US Code 2101 and 2104
2. PRINCIPAL PURPOSE(S): To provide information and data necessary for administering the Army Senior ROTC program, processing, and managing of selected students for commissioning in the Army IAW
established public law and Army Regulations.
3. ROUTINE USE(S): To provide a prjected academic plan to determine if the applicant meets the public law requirements of two remaining academic years.
4. VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is necessary to determine eligibility of the individual for acceptance,
continuance, or discontinuance in the Army ROTC program.
1. NAME OF STUDENT (LAST, FIRST, MI)                                       2. ACADEMIC MAJOR                                                       3. AS OF DATE (MM/DD/YYYY) (Date of form preparation)
-                                                                            -
4. INSTITUTION OF ATTENDANCE AND IDENTIFICATION                              5. CREDIT HOURS                                                   6. GRADE POINT AVERAGE (GPA)
a. Name:                University of Illinois at Urbana-Champaign           Select Semester or Quarter (S/Q)                S                       Term:                                   Term:
b.    Identification (Check one):                  Host X                    a. Total required for degree:                                       Curr GPA:        CUM:                  Curr GPA:         CUM:
                                           Extension Center                      (1) ROTC Hours that do not count:                                   Term:                                   Term:
                                             Cross-Enrolled                      (2) Total Hours Rqd for NAPS:                   0               Curr GPA:        CUM:                  Curr GPA:         CUM:
c. If attendance is at an extension center or cross-enrolled school,         Normal Academic Progression Standard           0.00                     Term:                                   Term:
list the name of the Host Institution:                                       b. Transfer Credits accepted:                                       Curr GPA:        CUM:                  Curr GPA:         CUM:
                                                                             c. Credits toward degree Comp to date:                                  Term:                                   Term:
                                                                             d. Reamining for Degree:                            0               Curr GPA:        CUM:                  Curr GPA:         CUM:
                                                                             e. Number of authorized S/Qs:                       0                   Term:                                   Term:
                                                                                                                                                 Curr GPA:        CUM:                  Curr GPA:         CUM:
7.       TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES.
                                      a.                                                                b.                                                                    c.
              Term:                                        Year:                  Term:                                     Year:                   Term:                                                 Year:
             No.              Course Title            Hrs. Cts. Grd.             No.              Course Title        Hrs. Cts.   Grd.             No.                   Course Title                Hrs. Cts. Grd.

          MILS 101 Intro to Mil Sci                    2                      MILS 102 Basic Leadership                2
          MILS 112 Lab                                 0                      MILS 114 Lab                             0




                        Total Term Hours:              2      0                            Total Term Hours:           2     0                                    Total Term Hours:                   0    0
                                      d.                                                                e.                                                                    f.
              Term:                                        Year:                  Term:                                     Year:                   Term:                                                 Year:
             No.              Course Title            Hrs. Cts. Grd.             No.              Course Title        Hrs. Cts.   Grd.             No.                   Course Title                Hrs. Cts. Grd.

          MILS 201 Leadership Studies                  2                      MILS 202 Leadership and Teamwork         2
          MILS 212 Lab                                 0                      MILS 214




                        Total Term Hours:              2      0                            Total Term Hours:           2     0                                    Total Term Hours:                   0    0


8. STUDENT INITIALS & DATE:                             TERM 1:                                                        TERM 4:                                                     TERM 7:
    (Have the student initial and date beside each      TERM 2:                                                        TERM 5:                                                     TERM 8:
    term to indicate they have been counseled)          TERM 3:                                                        TERM 6:                                                     TERM 9:
CC Form 104-R, NOV 2010                                                                                                                                                                                        Page 1 of 3
                                                                               PLANNED ACADEMIC PROGRAM WORKSHEET
                                                                   For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PA-C
7.    TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES. (CONTINUED)
                                g.                                                                     h.                                                                        i.
               Term:                                  Year:                     Term:                                        Year:                    Term:                                                Year:
              No.          Course Title          Hrs. Cts. Grd.                No.                Course Title         Hrs. Cts.   Grd.              No.                   Course Title               Hrs. Cts. Grd.

       MILS 301 Leadership/Problem Solving        3                         MILS 302 Leadership and Ethics              3
       MILS 312 Lab                               0                         MILS 314 Lab                                0




                       Total Term Hours:          3     0                                 Total Term Hours:             3     0                                     Total Term Hours:                   0      0

                                j.                                                                     k.                                                                        l.
               Term:                                  Year:                     Term:                                        Year:                    Term:                                                Year:
              No.          Course Title          Hrs. Cts. Grd.                No.                Course Title         Hrs. Cts.   Grd.              No.                   Course Title               Hrs. Cts. Grd.

       MILS 341 Leadership and Management         3                         MILS 342 Officership                        3
       MILS 322 Lab                               0                         MILS 324 Lab                                0




                       Total Term Hours:          3     0                                 Total Term Hours:             3     0                                     Total Term Hours:                   0      0

                               m.                                                                      n.                                                                       o.
               Term:                                  Year:                     Term:                                        Year:                    Term:                                                Year:
              No.          Course Title          Hrs. Cts. Grd.                No.                Course Title         Hrs. Cts.   Grd.              No.                   Course Title               Hrs. Cts. Grd.




                       Total Term Hours:          0     0                                 Total Term Hours:             0     0                                     Total Term Hours:                   0      0



9. REVIEW: All of the above courses are required (as minimum) for the completion of the degree:             Yes                           No (if no, list exceptions on reverside of this form). Completion should

result in a                                                                                   degree, during (YYMM):

10. SIGNATURE OF STUDENT:                                                                                                                         11. DATE: (MM/DD/YYYY)




12. SIGNATURE OF REGISTRAR AND EXAMINER OF CREDENTIALS (OR OTHER INSTITUTION CERTIFYING OFFICIAL):                                                13. DATE: (MM/DD/YYYY)




CC Form 104-R, NOV 2010                                                                                                                                                                                              Page 2 of 3
                                                            PLANNED ACADEMIC PROGRAM WORKSHEET
                                                   For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PA-C



                                                             STATEMENT OF UNDERSTANDING

     We, the undersigned, hereby declare that the program outlined on the worksheet (on the reverse side of this statement) that


   Cadet                      -                 is about to under take a formally structured program approved by               University of Illinois at Urbana-Champaign
                 (FULL NAME, Last, First, MI)                                                                                           (Name of University or College)



   designed to meet the requirments of a                             -                        degree; that the degree to be attained is the culmination of an
                                                              (Type of Degree)



   undergraduate college program of at least four years; and that the remaining credit hours shown on the worksheet are necessary either to fulfill


   discipline requirements or to fulfill credit hour requirements, or both, for the attainment of the degree. If the cadet is an ROTC Scholarship


   participant, the scholarship will be in force for the number of semesters indicated in Block 5.




             (Date) (MM/DD/YYYY)                                             (CADET SIGNATURE)




             (Date) (MM/DD/YYYY)                            (PROFESSOR OF MILITARY SCIENCE SIGNATURE)




CC Form 104-R, NOV 2010                                                                                                                                                   Page 3 of 3
                          Enroll in Military Science Classes (Basic Course)
                                                UIUC
Below are the Military Science Classes to register for if you are attending UIUC.
Freshman:
    Fall Semester: Military Science (MILS) 101 – Foundations of Officership (Pick one class session) (2 Hrs)
      Section           Time                      Days                   CRN             Room
           A            10:00-10:50 a.m.          M,W                    32542           313 Armory Bldg
           B            11:00-11:50 a.m.          M,W                    32546           313 Armory Bldg
           C            10:00-10:50 a.m.          T,R                    41854           313 Armory Bldg
           D            11:00-11:50 a.m.          T,R                    32550           313 Armory Bldg
           E            Arranged                  ARR                    41855           ARR

                        Military Science (MILS) 112 – Leadership Laboratory (attend ALL lab times below) (0 Hrs)
      Section           Time                     Days                   CRN            Room
         A              6:00-7:30 a.m.           M,W,F                  30525          Armory Floor
        and             4:00-5:30 p.m.           R

    Spring Semester: Military Science (MILS) 102 – Basic Leadership (Pick one class session) (2 Hrs)
       Section         Time                      Days                   CRN              Room
          A            10:00-10:50 a.m.          M, W                   34414            313 Armory Bldg
          B            11:00-11:50 a.m.          M,W                    34417            313 Armory Bldg
          C            10:00-10:50 a.m.          T, R                   34419            313 Armory Bldg
          D            11:00-11:50 a.m.          T, R                   34423            313 Armory Bldg
          E            Arranged                  ARR                    34426            ARR

                        Military Science (MILS) 114 – Leadership Laboratory (attend ALL lab times below) (0 Hrs)
      Section           Time                     Days                   CRN            Room
         A              6:00-7:30 a.m.           M,W,F                  34429          Armory Floor
        and             4:00-5:30 p.m.           R

Sophomore:
    Fall Semester: Military Science (MILS) 201: Individual Leadership Studies (Pick one class session) (2 Hrs)
      Section           Time                     Days                    CRN             Room
           A            10:00-10:50 a.m.         M, W                    32555           132D Armory Bldg
           B            11:00-11:50 a.m.         M,W                     32558           132D Armory Bldg
           C            10:00-10:50 a.m.         T, R                    32560           132D Armory Bldg
           D            11:00-11:50 a.m.         T, R                    32562           132D Armory Bldg
           E            Arranged                 ARR                     32564           ARR

                        Military Science (MILS) 212 – Leadership Laboratory (attend ALL lab times below) (0 Hrs)
      Section           Time                     Days                   CRN            Room
         A              6:00-7:30 a.m.           M,W,F                  30532          Armory Floor
        and             4:00-5:30 p.m.           R

    Spring Semester: Military Science (MILS) 202: Leadership and Teamwork (Pick one class session)
       Section         Time                      Days                 CRN             Room
          A            10:00-10:50 a.m.          M, W                 34434           132D Armory Bldg
          B            11:00-11:50 a.m.          M,W                  34436           132D Armory Bldg
          C            10:00-10:50 a.m.          T, R                 34439           132D Armory Bldg
          D            11:00-11:50 a.m.          T, R                 34442           132D Armory Bldg
          E            Arranged                  ARR                  34446           ARR

                        Military Science (MILS) 214 – Leadership Laboratory (attend ALL lab times below) (0 Hrs)
      Section           Time                     Days                   CRN            Room
         A              6:00-7:30 a.m.           M,W,F                  34448          Armory Floor
        and             4:00-5:30 p.m.           R
                        Enroll in Military Science Classes (Advanced Course)
                    Below are the Military Science Classes to register for the Advanced Course

Junior:
     Fall Semester: Military Science (MILS) 301: Leadership Problem Solving (Pick one class session) (3 Hrs)
       Section           Time                     Days                   CRN             Room
           A             2:30-4:00 p.m.           T, R                   32566           313 Armory Bldg
            B            2:30-4:00 p.m.           M,W                    32567           313 Armory Bldg
            E            Arranged                 ARR                    32569           ARR

                         Military Science (MILS) 312: Leadership Laboratory (attend ALL lab times below) (0 Hrs)
          Section        Time                     Days                  CRN            Room
             A           6:00-7:30 a.m.           M,W,F                 30540          Armory Floor
            and
                         4:00-5:30 p.m.   R

     Spring Semester: Military Science (MILS) 302: Leadership and Ethics (Pick one class session) (3 Hrs)
        Section         Time                      Days                   CRN              Room
           A            2:30-3:50 p.m.            T,R                    34451            313 Armory Bldg
           B            2:30-3:50 p.m.            M,W                    34455            313 Armory Bldg
           E            Arranged                  ARR                    42969            ARR

                         Military Science (MILS) 314: Leadership Laboratory (attend ALL lab times below) (0 Hrs)
          Section        Time                     Days                  CRN             Room
             A           6:00-7:30 a.m.           M,T,W,R,F             34458           Armory Floor
            and
                         4:00-5:30 p.m.            R

Senior:
     Fall Semester: Military Science (MILS) 341:   Leadership and Management (Pick one class session) (3 Hrs)
       Section           Time                       Days                 CRN             Room
           A             7:30-8:50 a.m.             M,W                  32570           313 Armory Bldg
            E            Arranged                   ARR                  32573           ARR

                         Military Science (MILS) 322: Leadership Laboratory (attend ALL lab times below) (0 Hrs)
          Section        Time                     Days                  CRN            Room
             A           6:00-7:30 a.m.           M,T,W,R,F             32575          Armory Floor
            and
                         4:00-5:30 p.m.            R
             B           ARR                       ARR                    32584           ARR

     Spring Semester: Military Science (MILS) 342: Leadership and Ethics (Pick one class session) (3 Hrs)
        Section         Time                      Days                    CRN             Room
           A            7:30-8:50 a.m.            M,W                     34500           313 Armory Bldg
           E            Arranged                  ARR                     34504           ARR

                         Military Science (MIL S) 324: Leadership Laboratory (attend ALL lab times below) (0 Hrs)
          Section        Time                      Days                  CRN            Room
             A           6:00-7:30 a.m.            M,T,W,R,F             34507          313 Armory Bldg
            and
                         4:00-5:30 p.m.            R
             C           ARR                       ARR                    34512           ARR
                              Enroll in Military Science Classes (Basic Course)
                                              Parkland College
Below are the Military Science Classes to register for if you are attending Parkland College
   Military Science classes through Parkland College are held on the University of Illinois at Urbana-Champaign campus. In order to enroll
   in these courses, all Parkland College students must register through Jennifer Harbaugh in the Parkland Admissions Office –room A165.
   Her number is 217-353-2636. email: jharbaugh@parkland.edu and then come to room 113W Armory Building on the UIUC campus.

Freshman:
      Fall Semester: MSC 101 - Foundations of Officership (Pick one class session)
        Section         Time                        Days                    Room in Armory Bldg on UIUC Campus
            A           10:00-10:50 a.m.            M,W                     313 Armory Bldg
             B          11:00-11:50 a.m.            M,W                     313 Armory Bldg
             C          10:00-10:50 a.m.            T,R                     313 Armory Bldg
            D           11:00-11:50 a.m.            T,R                     313 Armory Bldg
             E          Arranged                    ARR                     ARR
AND
                          Leadership Laboratory (attend ALL lab times below)
        Section           Time                     Days                   Room in Armory Bldg on UIUC Campus
           A              6:00-7:30 a.m.           M,W,F                  Armory Floor
          and             4:00-5:30 p.m.           R

      Spring Semester: MSC 102 - – Basic Leadership (Pick one class session)
         Section        Time                       Days                     Room in Armory Bldg on UIUC Campus
            A           10:00-10:50 a.m.           M, W                     313 Armory Bldg
            B           11:00-11:50 a.m.           M,W                      313 Armory Bldg
            C           10:00-10:50 a.m.           T, R                     313 Armory Bldg
            D           11:00-11:50 a.m.           T, R                     313 Armory Bldg
            E           Arranged                   ARR                      ARR
AND
                          Leadership Laboratory (attend ALL lab times below)
        Section           Time                     Days                   Room in Armory Bldg on UIUC Campus
           A              6:00-7:30 a.m.           M,W,F                  Armory Floor
          and             4:00-5:30 p.m.           R

Sophomore:
      Fall Semester: MSC 103: Individual Leadership Studies (Pick one class session)
        Section         Time                       Days                    Room in Armory Bldg on UIUC Campus
            A           10:00-10:50 a.m.           M, W                    132D Armory Bldg
             B          11:00-11:50 a.m.           M,W                     132D Armory Bldg
             C          10:00-10:50 a.m.           T, R                    132D Armory Bldg
            D           11:00-11:50 a.m.           T, R                    132D Armory Bldg
             E          Arranged                   ARR                     ARR
AND
                          Leadership Laboratory (attend ALL lab times below)
        Section           Time                     Days                   Room in Armory Bldg on UIUC Campus
           A              6:00-7:30 a.m.           M,W,F                  Armory Floor
          and             4:00-5:30 p.m.           R

    Spring Semester: MSC 105: Leadership and Teamwork (Pick one class session)
       Section        Time                      Days                  Room in Armory Bldg on UIUC Campus
          A           10:00-10:50 a.m.          M, W                  132D Armory Bldg
          B           11:00-11:50 a.m.          M,W                   132D Armory Bldg
          C           10:00-10:50 a.m.          T, R                  132D Armory Bldg
          D           11:00-11:50 a.m.          T, R                  132D Armory Bldg
          E           Arranged                  ARR                   ARR
AND                   Leadership Laboratory (attend ALL lab times below)
       Section        Time                      Days                  Room in Armory Bldg on UIUC Campus
          A           6:00-7:30 a.m.            M,W, F                Armory Floor
         and          4:00-5:30 p.m.            R
                         Military Science Course Requirements

                              Professional Military Education Courses

In addition to the Military Science Classes all cadets need to take one additional class called
Professional Military Education Course. The list of acceptable courses follows:

Military History (3 or more credit hours):

Naval Science 323      3hrs    History of Amphibious Warfare
GEOG 110               3hrs    Geography of International Conflicts

For more information about the Planned Academic Worksheet (104-R) and the PME
requirements, please see Mr. Kraus at 217-244-7763 or kekraus@illinois.edu.

				
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