ROTC ECP Application Form - Valley Forge Military Academy and College

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 Country
Home Phone
Date of Birth*
Social Security Number*
Place of Birth*
U.S. Citizen*

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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

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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.

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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

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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*

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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*

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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*

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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

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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*
Was the applicant a member, letter, captain or all district? Please explain what grades and participation level
Sports*
Was the applicant a member, letter, captain or all district? Please explain what grades and participation level
Sports*
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

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Extracurricular Activities
Activities*
Years in each activity?
Activities*
Years in each activity?
Activities*
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*

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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*

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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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About VFMAC

Established in 1928, Valley Forge Military Academy and College is an international leadership institution, comprised of a middle school, high school, and college. The College has been designated by the Governor and Legislature as the Military College of Pennsylvania.™

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