THE AMERICAN LEGION HOOSIER BOYS STATE

DELEGATE APPLICATION

( Please Print or Type )

PAYMENT METHOD

AMOUNT _______________

CHECK #  _______________

MONEY ORDER _________

Post use Only

SPONSOR _________

POST         _________

DISTRICT _________

 

NAME ____________________________________________________________________________

                   (First)                               (Middle)                                   (Last)

 

ADDRESS _________________________________________________________________________

 

 

CITY ________________________COUNTY ______________STATE ________ZIP ____________

 

 

PHONE  (      ) ________________________AGE __________ email __________________________

 

 

Would you like to play in the HBS Marching Band ?          (Circle One)        YES      NO

 

Instrument played ___________________ Bring it ?           (Circle One)        YES      NO     

 

 

 

(School Certification)

I certify that the applicant will complete his junior year following this semester, has at least one more semester’s credits to graduation, that he is a good school citizen, has a good attitude, and exhibits good conduct.

 

_________________________________________________

                                Principal or Superintendent

 

__________________________________________________

                                      Name of High School

 

__________________________________________________

                                           Post Official

 

 

 

                                                                                                                                                                                                                                     Date _________________

 

 

The undersigned parent and/or guardian of __________________________________________________, a minor, do hereby authorize Indiana State University Health

                                                                                                    (Please Print Student’s Name)

 

Center, its doctors and nurses, and Union Hospital, to treat and/or prescribe medications to the above named minor while enrolled or participating in any activity under the

 

auspices of Indiana State University.

 

                                                                                                                                           ______________________________________________

                                                                                                                                                             Signature of Parent or Guardian   

                                                                                                                                            

                                                                                                                                            Phone #  _________________________________

THE AMERICNA LEGION HOOSIER BOYS STATE

WAIVER OF LIABILITY

 

(MUST SIGNED BY PARENT or GUARDIAN)

 

In consideration of the benefits derived if application is accepted, I hereby voluntarily waive any claim against The American Legion for any and all causes which may arise in connection with the activites of the above organization.

 

                                                                                                                                                                             ________________________________________________________

                                                                                                                                                                                                           (Signature of Parent of Guardian)     

 

                                                                                                                                                                              ______________________________________

                                                                                                                                                                 Phone Number                 

 

 

American Legion Hoosier Boys State Medical Certificate

(Copy of IHSAA Physical acceptable if taken within last 12 months)

 

 

NAME ___________________________________________________________________________________

 

ADDRESS _________________________________________________CITY __________________________STATE __________ ZIP ____________

 

Any abnormality or allergies ___________________________________________________

 

Heart: __________ Skin: __________Lungs: __________ Throat: __________ Eyes: __________ Ears: __________

 

Extrementies: __________Asthma: __________ Abdominal: __________ Diabetes: __________ Medications: ___________________

 

 

Can He participate in strenuous athletic programs: __________ Any special medical conditions staff should be aware of: __________________________________

 

If so, what and your recommendations: ____________________________________________________________________________________________________

 

 

 

                                                                        Physician's Signature __________________________________________________  Date: _______________________