Military Academy Medical Waiver Request Form

Applicant Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Preferred Contact Method

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Academy Name

Program / Class Year or Cadet Status

Request Type / Category

Date Waiver Is Needed By

Date

Description of Waiver or Review Requested

Request Status

Medical condition or concern

Date of diagnosis or onset

Date

Condition status

Current treatment status

Current restrictions or limitations

Explain how this condition affects academy duties or training

Medications, therapies, or other relevant treatment details

Physician Notes

Diagnostic Reports

Treatment Summaries

Clearance Letters

Treating Physician/Provider Name

First NameMiddle NameLast Name

Emergency Contact Name

First NameLast Name

Relationship to Applicant

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Follow-up Communication Preference and Prior Waiver History

Signature

Date of Submission

Date

Military Academy Medical Waiver Request Form

Applicant Information

Academy and Waiver Request Details

Medical Information

Supporting Documentation and Provider Information

Emergency and Follow-up Details

Acknowledgment and Signature