Army ROTC Related Forms
Basic Course (Initial Enrollment Forms)
CC Form 139-R – Cadet Enrollment Record (Excel)
CC Form 136-R – Briefing on Government Benefits (Word)
CC Form 137-R – Release of Student Records (Excel)
DA Form 3425-R – Basic Course Medical Fitness Statement (PDF-Fillable)
Dental Memo
Advanced Course Forms (Contracting Forms)
DA 597 – ROTC Non-Scholarship Contract (PDF)
DA 597-3 – ROTC Scholarship Contract (PDF)
DD Form 4 – Enlistment Document (PDF-Fillable)
DD Form 93 – Record of Emergency Data (PDF-Fillable)
DD Form 2005 – Privacy Act Statement – Health Care Record (PDF-Fillable)
DD Form 2058 – State of Legal Residence (PDF-Fillable)
SF 1199 – Direct Deposit Sign Up Form (PDF-Fillable)
SGLV 8286 – Soldier’s Group Life Insurance Form (PDF-Fillable)
W-4 – Employee Withholding Allowance Certificate (PDF-Fillable)
CC Form 104-R – Academic Alignment Sheet (Excel)
CC Form 104-R Instructions
Initial Contract Counselling
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 w ith my participation in the Army ROTC program, I
hereby authorize the release of any and
(Cadet' s Name)
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 w aive any requirement that I be furnished a copy of those records prior to or concurrent w ith their
release. This consent remains effective until my relationship w ith 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
ROTC Department to my
(Name of School)
parents. (Exception: Parents w ho still claim student as a dependent for IRS purposes) If I change my mind in the
future, I w ill inform the ROTC Department in w riting.
Signature of Cadet
CC FORM 137-R, AUG 02
Date
PREVIOUS EDITIONS ARE OBSOLETE
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
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 th
continuance, or discontinuance in the Army ROTC program.
1. NAME OF STUDENT (LAST, FIRST, MI)
2. ACADEMIC MAJOR
3. AS OF
6. GRADE
4. INSTITUTION OF ATTENDANCE AND IDENTIFICATION
5. CREDIT HOURS
a. Name:
Select Semester or Quarter (S/Q)
b. Identification (Check one):
Host
S
Term
a. Total required for degree:
Extension Center
Curr GPA
(1) ROTC Hours that do not count:
Cross-Enrolled
Term
0
(2) Total Hours Rqd for NAPS:
c. If attendance is at an extension center or cross-enrolled school,
list the name of the Host Institution:
0.00
Normal Academic Progression Standard
b. Transfer Credits accepted:
Curr GPA
Term
Curr GPA
c. Credits toward degree Comp to date:
Term
d. Reamining for Degree:
0
e. Number of authorized S/Qs:
0
Curr GPA
Term
Curr GPA
7.
TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DE
a.
Term:
No.
Course Title
Total Term Hours:
b.
Year:
Hrs. Cts. Grd.
0
Term:
No.
Total Term Hours:
0
d.
Term:
No.
Course Title
Total Term Hours:
Course Title
Year:
Hrs. Cts.
Grd.
0
0
e.
Year:
Hrs. Cts. Grd.
0
0
Term:
No.
Course Title
Total Term Hours:
Year:
Hrs. Cts.
Grd.
0
0
8. STUDENT INITIALS & DATE:
TERM 1:
TERM 4:
(Have the student initial and date beside each
term to indicate they have been counseled)
TERM 2:
TERM 5:
TERM 3:
TERM 6:
CC Form 104-R, DEC 04
Term
No.
Term
No.
CADET ENROLLMENT RECORD
For use of this form, see CC Pam 145-4, the proponent agency is ATCC-P
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Authority
Principal Purpose(s)
10 USC 2101, 2103, 2104, 2107, 2111, and 5 USC 301
To obtain personnel data in order to determine eligibility for enrollment and serve as a source document for cadet's service record th
administration of the ROTC student commencing with application for enrollment into the ROTC Program.
To verify eligibility to participate in the ROTC Program; to provide information on addresses and telephone numbers for use in the e
participating in ROTC activities; to facilitate contact with complete information with a cadet during other than normal training periods
Disclosure is voluntary. However, failure to provide complete information and provide responses will suspend the enrollment proces
Routine Uses
Disclosure
PART I - GENERAL INFORMATION
1. NAME
2. SSN
3. COLLEGE ID #
4.
5. LOCAL ADDRESS
5a. CITY
5b. STATE
7. PERMANENT ADDRESS
7a. CITY
7b. STATE
9. DOB
10. POB
15. SEX
5c. ZIP
11. RELIGIOUS PREF
16. HEIGHT
17. WEIGHT
20. RACE/ETHNICITY (Check One)
African American
21. CITIZENSHIP (Check One)
U.S. Citizen:
18. MARITAL STATUS
American Indian
U.S. Born
Non U.S. Citizen:
19. DEPENDENTS
Asian
Caucasian
Naturalized
Immigrant Alien
Born Overseas With U.S. Parents
Nonimmigrant Alien
Refugee
22. Do you have any condition that could interfere with you participating in a normal college physical education course?
23. Have you ever received Medical Disability payments from any source?
24. NEXT OF KIN
His
22a. If "yes" explain
23a. If "yes" explain
24a. ADDRESS
PART II - ACADEMIC INFORMATION
25. ROTC HOST SCHOOL
25a. FICE CODE
27. RESIDENCY STATUS
28. ACADEMIC CLASS
31. ACADEMIC MINOR
26. SCHOOL OF ATTENDANCE
29. PROJECTED GRADUATION DATE
32. CREDITS TOWARD DEGREE
35. OTHER COLLEGES ATTENDED
30. ACA
33. CREDITS REQUIRED
35a. YEAR(S) ATTENDED
36a. GRADUATION DATE
37. ROTC SCHOLARSHIP RECIPIENT
36
37a. If "
38. OTHER SCHOLARSHIPS
39
PART III - CURRENT OR PRIOR MILITARY SERVICE (TO INCLUDE OFFICER PRO
NOT APPLICABLE (Go to PART IV)
40. CURRENT SERVICE:
Are you currently in the Armed Forces?
40a. If "yes"
40b. SMP UNIT
41. PRIOR SERVICE:
Have you ever been enrolled in an officer producing program?
41b. Were you ever enrolled in a Service Academy?
41f. Months of Active Service
CC Form 139-R, DEC 07
41a. Were you ever disenrolled from the ROTC Program
41c. Were you ever discharged from the Armed Forces?
41g. Have you ever been discharged for medical reasons?
41d. If "yes" what type of dis
41 h. If "yes", explain:
REPLACES ALL PREVIOUS EDITIONS, WHICH ARE OBSOLETE.
C-4. Preparation for the Planned Academic Program Worksheet (CC FM 104-R,
Dec 04) are as follows:
a. The CC FM 104-R will be completed for each applicant/cadet who is contracting to
ensure academic alignment. The intent of this form is to input the data on the PC to
prevent errors, especially in the formulas.
b. Preparation of this form is self-explanatory. When the various Blocks are “chosen”, a
“What’s This?” message block will appear which provides instructions for entering
correct data in each block. Once the information in Block 1 and Block 4a of page 1, and
Block 9 of page 2 is entered, the same information will automatically populate page 3,
Statement of Understanding.
c. Block 5. Credit Hours. Items in Block 5 will automatically calculate when data is
entered. Block 5 will calculate both semester and quarter hours. From the drop down
menu box, select “S” for semester and “Q” for quarter system. A sample with
instructions for completion of Block 5 is below—
SAMPLE
5. CREDIT HOURS
a. Total hours required for degree
(Does not include ROTC)
(1) ROTC Hours that do not count
120
20
(Include any ROTC hours that do not count towards the degree to
ensure academic and military alignment is maintained
(2) Total Hours Required (automatically calculated)
Normal Academic Progression Standard (NAPS) (automatically
calculated)
140
17.50
(The Total Hours Required divided by the total number of
semesters/quarters established in the school catalog to complete the
degree + ROTC hours). In this sample, 120 hours (which is normally a
4-year academic program), and eight (8) semesters was used to
calculate the academics + ROTC hours required (e.g., 140/8 = 17.50).
This is the normal academic progression required per semester in order
to remain academically aligned.
b. Transfer credits accepted toward degree (Based on institutional
certifying official)
45
c. Credits toward degree completed to date
30
d. Remaining for Degree, e.g., 140 - (45 + 30) = 65 (automatically
calculated)
65
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 offpost, 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
__________________________________
Printed Name of Cadet
CC FM 136-R, Aug 01
DEPARTMENT OF THE ARMY
U.S. ARMY ROTC BATTALION
WORCESTER POLYTECHNIC INSTITUTE
100 INSTITUTE ROAD
WORCESTER MA 01609-2280
REPLY TO
ATTENTION OF:
ATOE-AMA-WP
MEMORANDUM FOR Professor of Military Science
SUBJECT: Statement of Acknowledgement for Civilian Dental Records
_________ I have verified with my dentist that my dental records do contain descriptive profiles,
bite wing x-rays, orthodontic profiles or dental x-rays for identification purposes.
OR
_________ I have verified with my dentist that my dental records do not contain descriptive
profiles, bite wing x-rays, orthodontic profiles or dental x-rays for identification
purposes and have scheduled an appointment.
My appointment is scheduled for (Date) ______________ (Time)__________
Dentist Name: ____________________________________ Phone: ____________________
Address: ___________________________________________________________________
____________________________________ _____________________________________
(CADET PRINT NAME)
(CADET SIGNATURE)
____________________________________
(DATE)
INITIAL CONTRACTING COUNSELING
1.
I have read and fully understand the terms of my ROTC contract.
2. In addition to my ROTC contract and/or further explaining the
requirements therein, the following are requirements for my retention
as a contracted cadet:
a. I must maintain required DA height/weight standards (IAW AR
600-9).
b. I must pass a record APFT once per semester (with a minimum of
60 points per event).
c. I must maintain a Normal Academic Progression Standard (NAPS)
(12-15 credit hours for full and 6-9 credit hours for terms); not
including military science courses). I must make academic progress
toward graduation in the time line set up in my Planned Academic
Worksheet that I and my academic advisor must sign. I must also
register for and take a ROTC class each semester/term while I am in
school.
d. I must maintain a cumulative academic GPA of 2.0. I must also
maintain a semester and overall ROTC GPA of 2.0 (for non-scholarship
and scholarship cadets).
e. I must satisfy my professional military education (PME)
requirement prior to commissioning by:
(1)
Receiving a baccalaureate degree
(2) Completing MSL Advanced Course in sequence (MSL 301
through MSL 402)
(3) Demonstrating proficiency in military history either by
taking the ROTC Military History course or taking a PMS approved
academic course through the university I attend.
3. If I do not maintain retention standards (e.g. academic/ROTC GPA,
APFT and/or height/weight failure, misconduct, etc.) I may be placed
on administrative suspension (if a scholarship Cadet) which is
forfeiture of my scholarship benefits and book money for a specific
school term. During the suspension I must continue to fully
participate in ROTC and I will only receive my stipend. As a
scholarship cadet, probation is used in very rare cases, which involve
mitigating circumstances beyond the Cadet’s control. Failure to
correct a deficiency may result in continued forfeiture of my
scholarship benefits and book money, termination of my scholarship, or
initiation of disenrollment action.