Get ARPC IMT 77 2005-2024

MEMBER INFORMATION NAME Last Name First MI DATE SIGNATURE DOB SCHOOL S NAME SCHOOL S ADDRESS Include Zip Code PAGE 1 OF DEPENDENT INFORMATION SEX SCHOOL GRADE SCHOOL S PHONE NUMBER Include Area Code DIRECTIONS TO SCHOOL AFTER CARE FACILITY/ROUTINE CARE PROVIDER PROVIDER S NAME PROVIDER S ADDRESS Include Zip Code PROVIDER S PHONE NUMBER Include Area Code SPECIAL NEEDS OR UNIQUE SITUATIONS PLEASE LIST ANY SPECIAL MEDICAL NEEDS LANGUAGE LIMITATIONS OR OTHER UNIQUE SITUATIONS Attention disorder speech impediments medication phobias etc. ARPC IMT 77 20050822 V1 PREVIOUS EDITIONS ARE OBSOLETE. This is a web-optimized version of this form* Download the original full version www. usa-federal-forms. com/download*html Convert any form into fillable savable www. fillable. com Learn how to use fillable savable forms Demos www. fillable. com/demos. html Examples www. fillable. com/examples. html Browse/search 10 s of 1000 s of U*S* federal forms converted into fillable savable FAMILY CARE PLAN ADDITIONAL INFORMATION SHEET Attachment to Completed AF Form 357 In accordance with AFI 36-2908 paragraph 2. 8. 2. 6 Family Care Plans the following additional information is required to assist my caregiver s and dependent s with the transition of care and to deal with my absence PRIVACY ACT STATEMENT AUTHORITY Title 10 U*S*C. 8013 and E*O. 9397 Secretary of the Air Force powers and duties delegation by. PRINCIPAL PURPOSE To contact persons designated by the member as accepting family care responsibility to verify their willingness to act for the member in this capacity to advise the caregivers when they are expected to discharge these responsibilities and to insure member s compliance with the instruction* ROUTINE USE None. DISCLOSURE IS VOLUNTARY Use of the SSN is required to establish positive identification* Other information is required to ensure members have met their family care responsibilities. Failure to provide the information may result in discharge from the Active Air Force Air National Guard or Air Force Reserve. This is a web-optimized version of this form* Download the original full version www. usa-federal-forms. com/download*html Convert any form into fillable savable www. fillable. com Learn how to use fillable savable forms Demos www. com/download*html Convert any form into fillable savable www. fillable. com Learn how to use fillable savable forms Demos www. fillable. com/demos. html Examples www. fillable. com/examples. html Browse/search 10 s of 1000 s of U*S* federal forms converted into fillable savable FAMILY CARE PLAN ADDITIONAL INFORMATION SHEET Attachment to Completed AF Form 357 In accordance with AFI 36-2908 paragraph 2. fillable. com/demos. html Examples www. fillable. com/examples. html Browse/search 10 s of 1000 s of U*S* federal forms converted into fillable savable FAMILY CARE PLAN ADDITIONAL INFORMATION SHEET Attachment to Completed AF Form 357 In accordance with AFI 36-2908 paragraph 2. 8. 2. 6 Family Care Plans the following additional information is required to assist my caregiver s and dependent s with the transition of care and to deal with my absence PRIVACY ACT STATEMENT AUTHORITY Title 10 U*S*C. .