TEXAS AMERICAN LEGION BOYS STATE
Please type or print legibly. This entire form must be completed for each ID#
Applicant. Signatures are required on this form by all individuals making
statements on form. Forward this form and any other correspondence to:
The American Legion, Department of Texas, Date Recv’d
P.O. Box 140527, Austin, TX 7871.
Last Name First Name Birth Date (mm-dd-yy)
Address City – State – Zip
Social Security Number Home Phone (Including Area Code) EMAIL:
PARENT or LEGAL GUARDIAN
Relation to Applicant Full Name
Address City – State – Zip.
Home Phone (Including Area Code) Work Phone (Including Area Code) Cell Phone (Including Area Code)
PHYSICIAN OF APPLICANT
Full Name Office Phone (Including Area Code)
Address City – State – Zip
Full Name Title or Position
Name of High School School District
Post Number Name of Post City – State – Zip
Name of Post Representative Home Phone of Post Official
Financial Sponsorship (Circle all applicable sources)
LEGION POST CIVIC ORGANIZATION SCHOOL DISTRICT INDIVIDUAL OTHER
I have completed the sections above and on the the side to the right of this form which pertains to me and
agree to the terms of certification or pledge that all statements by me are true to the best of my knowledge.
Signature of Applicant Date (mm-dd-yy)
PARENT or Signature of Parent or Guardian Date (mm-dd-yy)
Signature of Physician Date (mm-dd-yy)
SCHOOL Signature of School Official Date (mm-dd-yy)
LEGION Signature of Legion Official Date (mm-dd-yy)
Last Name First Name Nick Name
MEDICAL CERTIFICATES & PLEDGE
Have you ever had any of the following?
Chicken Pox Diphtheria Ear/Sinus Trouble Heart Trouble
Infantile Paralysis Lung Trouble Measles Mumps
Pneumonia Scarlett Fever Small Pox Typhoid Fever
Have you been exposed to any contagious diseases within the last 3weeks? Yes No
Have you had any reactions of any kind from taking prescription or non-prescription drugs or medicine? If so please explain.
Have you had inoculations for Whooping Cough, Diphtheria, or Tetanus? If so when.
TEXAS AMERICAN LEGION BOYS STATE PLEDGE
I pledge allegiance to the flag of the United States of America and to the republic for which it
stands. I have never attended The American Legion Boys State, and if accepted, will, to the best
of my ability: 1) take a serious and concientious interest in discharging my duties as a citizen; 2) Obey the rules of Boys State; 3) Respect the judgement of the Boys State Director, the couselors, and the staff; 4) Participate in all activities; 5) Seek election or appointment to office, and if elected
or appointed, serve that office; 6) Keep myself neat and well groomed at all times; 7) Avoid the use of profane language and actions; 8) refrain from injurous habits such as the use of tobacco, alcohol, and illicit drugs; and 9) Upon my return home from Boys State, make a formal oral or written report to my sponsor(s).
SCHOOL ADMINISTRATOR: School Certification
I hereby certify that the applicant meets all requirements of Texas American Legion Boys State
and has my approval to attend.
LEGION SPONSOR: Sponsoring Post Affidavit
I hereby certify that I have interviewed the applicant and he meets the eligibility requirements and selection criteria to be appointed as a delegate to Texas American Legion Boys State.
PARENT or LEGAL GUARDIAN:
This is to certify that I, the parent or guardian of the applicant do, in the event that my son
becomes a participating member of Texas American Legion Boys State to be held in Austin, Texas, hereby consent and grant permission, should the necessity of medical care arise, to the furnishing
of medical treatment and hospital services as ordered or recommended by a qualified attending physician or nurse, including the administration of an anesthetic, laboratory procedures, medical
or surgical treatment, x-ray or other hospital services. Consent is hereby granted to the attending physician(s), hospital(s), and/or clinic(s) to release necessary medical information to our local
doctors and for use in claims for insurance coverage. This will further certify that I, in consideration
of the benefits to be derived by my son, in the event that he is a member of Texas American
Legion Boys State to be held in Austin, Texas, do hereby release and discharge The American Legion, its officers, agents, instructors, and employees from any and all calms, demands,
damages, suits, actions, or causes of action which I may, can, or shall have by reason of any
illness, injury, or accident incurred or suffered by said son while traveling to or from, attending at,
or participating in Texas American Legion Boys State program from the time of his departure
from home until his return thereto.
My son is not covered with hospital insurance. My son has hospital coverage with:
PHYSICIAN: Physical Examination:
Please consider the ability of the stated applicant to be one of a large group of boys
physically fit and able to participate actively in this very active program.
CONDITION OF APPLICANT:
Is he ambulatory? Yes No Does he require medication or a special diet? Yes No
Check if further information is attached.