Valley Forge Military Academy and College
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ROTC ECP Online Application
ROTC ECP Online Application
Please fill in this form completely to submit and be considered for admission.
ROTC ECP and Medical
Combination of ECP App 2019 and Medical Pre Screen
Step
1
of
12
8%
Name
*
First
Last
Cell Phone
*
Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Date of Birth
*
Social Security Number
*
Place of Birth
*
U.S. Citizen
*
Yes
No
Academic Info
High School Attended
*
High School Address
*
High School Phone Number
*
High School Graduation Date
*
High School Guidance Counselor's Name
JROTC Participation
*
Yes
No
How many years in JROTC?
*
Senior Army Instructor's Name
*
First
Last
Have you applied for a three-year or four-year ROTC Scholarship?
*
Yes
No
Prior Service
Prior Service
*
No
Yes
Active
Reserves
National Guard
If discharged, enter Reenlistment Code
Unit Name
Unit Phone
Unit Address
Please select the appropriate form:
DD Form 4 (Guard and Reserve Only)
DA Form 220
DD Form 214
Please upload appropriate copy of above form:
Max. file size: 256 MB.
Measurements
Height (inches)
*
Weight (pounds)
*
Hat Size
*
Shoe Size
*
T-Shirt Size
*
Prior Convictions
Do you now or have you had any civil or criminal convictions?
*
Yes
No
Submit a statement of facts on a separate sheet of paper that includes circumstances, dates, actions, charges, results and satisfaction of sentence. Traffic tickets in excess of six per year or one totaling $250 or more requires a statement and/or waiver. (Note: Application will not be processed without statement.)
*
I agree
Medical Information
Have you taken a DODMERB Physical?
*
Yes
No
Do you have a history of asthma?
*
Yes
No
When was the last time you had an asthma attack?
Do you use asthma medication?
Yes
No
Have you ever taken the Methacholine Challenge Test (MCT)?
Yes
No
Have you ever been treated by a medical professional for psychological disorders (i.e. Depression, ADHD)?
*
Yes
No
Were any medications prescribed?
*
Yes
No
Are you currently taking medication?
*
Yes
No
How long have you been taking medication?
*
Do you have any academic accommodations at your school?
*
Yes
No
Do you have any allergies? (i.e. seasonal, food, bee sting)
*
Yes
No
Please specify allergies
*
Have you ever undergone immunotherapy?
*
Yes
No
Please list all current medications.
*
Do you currently have, or have you ever had joint injuries? (i.e. knee pain, hip or shoulder dislocation)
*
Yes
No
Please explain when and what joint injuries you have had? (i.e. knee pain, hip or shoulder dislocation)
*
Have you ever worn a support brace? (i.e. metal or cloth, this is not a neoprene type support band)
*
Yes
No
Do you currently wear a support brace?
*
Yes
No
For what injury do you wear a support brace?
*
How long did / have you worn the brace?
*
Have you ever been treated for any ocular disorders (disorders of the eye)?
*
Yes
No
Have you undergone Lasik Surgery?
*
Yes
No
When was the surgery or treatment?
*
Have you ever undergone a surgical procedure?
*
Yes
No
When was the surgical procedure(s)?
*
What condition was the surgical procedure(s) for?
*
Are there any medical conditions, not mentioned in this document, which you have been diagnosed with? (Please explain)
*
By signing this form, I acknowledge that I have disclosed any and all pre-screening medical conditions that would make me ineligible for enrollment in the ECP ROTC Program as specified in statute, and Army regulation (AR 145-1). Failure to disclose or to have disclosed my disqualifying conditions, including any conditions I should have known about, will subject me to disenrollment from the ROTC Program.
*
I agree
Printed Signature
*
Tattoo Information
Do you have any tattoos?
*
Yes
No
Do you have any tattoos on or above the neck (above the t-shirt line)?
*
Yes
No
Do you have any tattoos on or below the wrist?
*
Yes
No
Do you have any tattoos on or below the elbow?
*
Yes
No
Do you have any tattoos below the knee?
*
Yes
No
Do you have tattoos anywhere else on your body?
*
Yes
No
Please explain where your tattoos are located:
*
How may tattoos do you have total?
*
Tattoo Size (in inches). If you have more than one, please number them: example: (1) 3 inches (2) 2.5 inches
*
Description of tattoo (what does it represent). If you have more than one, please number them; example: (1) Mothers name (2) Flower represents peace.
*
Printed Signature
*
Leadership Training
If you have not attended Basic Training and AIT, you will be completing ROTC Basic Camp at Fort Knox, Kentucky. In order to better prepare our incoming cadets, we provide a four day Leaders Training Course (referred to as “mini camp”) on campus at Valley Forge Military College. We will contact you in the spring to coordinate travel arrangements. The Army pays for your travel to and from Army training to either the school, or your home of record. Note: the Army does not coordinate or pay for travel to report to school or during school holidays and breaks unless you are attending Army training during that time.
*
I understand
I have attended:
*
Army Basic Training
Army Basic Training and AIT
Neither
Acknowledgement
I certify that all information provided within this document is true and correct to the best of my knowledge. I submit this application subject to the penalties of Pennsylvania Criminal Code, Title 18, Section 4904, relating to unsworn falsification to authorities. I understand that if I have withheld or given false information, I may be denied admission or dismissed from the Army ROTC program at Valley Forge Military College.
*
I certify
DATA REQUIRED BY THE PRIVACY ACT OF 1974: 1. Authority: Title 10 USC 3012 (Section 2101 and 2111) 2. Principle Purpose: To obtain information to determine eligibility for participation in the Army ROTC Program; to provide information necessary for processing Basic Camp and advanced ROTC applications. 3. Routine Uses: To provide information on address and telephone numbers to facilitate contact with the candidate and his/her family; to make matter of record the physical characteristics of the candidate; to provide information essential for a fair evaluation of the candidate’s acceptability for Basic Camp attendance or advanced ROTC participation. 4. Mandatory or Voluntary Disclosure and Effect on Individual: Disclosure of Social Security Number is mandatory and required for identification. Failure to provide Social Security Number will preclude processing of the candidate’s application. Disclosure of all other information is voluntary; however, failure to provide all of the voluntary information may delay or prevent processing of applications for Basic Camp or entry into the ROTC advanced course.
*
I acknowledge
Printed Signature
*
ROTC Scholarship Applicant Snapshot
Data required by the Privacy Act of 1974 1. Authority: 10 USC 2101 and 2107 2. Principal Purpose(s) To physically identify each applicant 3. Routine Uses: To be used by the ROTC selection board in consideration of the applicant. 4. Mandatory or voluntary disclosure and effect on the individual for not providing the information: Use of this form is mandatory, applicant may not be considered if picture is not submitted.
*
I acknowledge
Printed Signature of Applicant
*
Hidden
SSN
Hidden
Current Height
Hidden
Current Weight
Extracurricular/Athletic/ Leadership Activities Record
Hidden
Name (Last, First, Middle)
Hidden
SSN
Instructions Indicate below your participation in extracurricular, athletic and leadership activities. Any recognized activity not listed should be in “other.” Be certain to indicate all leadership positions held. If additional space is needed, use the space provided in section E.
*
I understand
Athletic Activities
Sports
*
None
Baseball / Softball
Basketball
Boxing
Football
Golf
Gymnastics
Hockey
Soccer
Swimming
Track
Tennis
Wrestling
Rifle Team
Other (Please explain below)
Was the applicant a member, letter, captain or all district? Please explain what grades and participation level
Sports
*
None
Baseball / Softball
Basketball
Boxing
Football
Golf
Gymnastics
Hockey
Soccer
Swimming
Track
Tennis
Wrestling
Rifle Team
Other (Please explain below)
Was the applicant a member, letter, captain or all district? Please explain what grades and participation level
Sports
*
None
Baseball / Softball
Basketball
Boxing
Football
Golf
Gymnastics
Hockey
Soccer
Swimming
Track
Tennis
Wrestling
Rifle Team
Other (Please explain below)
Was the applicant a member, letter, captain or all district? Please explain what grades and participation level
Other:
Was the applicant a member, letter, captain or all district? Please explain what grades and participation level
Extracurricular Activities
Activities
*
None
Church Group
Debate
Dramatics
Scholastic Societies
School Band
School Newspaper
Student Newspaper
Student Government
Yearbook
Drill Team
Agriculture
Social Fraternities
Junior ROTC
Other (Please explain below)
Years in each activity?
Activities
*
None
Church Group
Debate
Dramatics
Scholastic Societies
School Band
School Newspaper
Student Newspaper
Student Government
Yearbook
Drill Team
Agriculture
Social Fraternities
Junior ROTC
Other (Please explain below)
Years in each activity?
Activities
*
None
Church Group
Debate
Dramatics
Scholastic Societies
School Band
School Newspaper
Student Newspaper
Student Government
Yearbook
Drill Team
Agriculture
Social Fraternities
Junior ROTC
Other (Please explain below)
Years in each activity?
Other:
Success achieved for each activity (awards, position of leadership, etc.)
Use this space to list any and all other activities/involvement to include employment. For work experience, please include the number of hours each week.
Printed Signature
*
Applicants Personal Statement
Full Name
*
Hidden
SSN
In 1 to 3 paragraphs, state in your own words why you desire to receive a commission as an Army Officer.
*
Printed Signature
*
Transcript and Test Score Upload
Please upload your High School Transcript
*
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Please upload your SAT and/or ACT scores
*
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
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