The American Legion Arizona Boys State Application Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutCell Phone *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home PhoneGrade (Numbers Only) *Email *EmailConfirm EmailName of School *Parent/Guardian InformationLayoutName *FirstLastPhone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmailConfirm EmailEmergency ContactLayoutName *FirstLastRelationship to Delegate *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Arizona Boys State may contact the above phone numbers or email addresses regarding problems with this application.Delegate ProfileScholastic and Honorary Awards *Extracurricular Activities *Special Considerations Requested *LayoutBus Information Requested? *BlankYesNoIs the Delegate the Direct Descendent of a Veteran? *BlankYesNoPayment ElectionArizona Boys State costs $450. This is typically paid as: $300 Tuition Fee, paid by the sponsoring American Legion Post or other Sponsor; and $150 Registration Fee, paid by the student Online payment includes a $5 convenience fee A Delegate who does not have a Sponsor must pay the full cost LayoutName of SponsorFirstLastIf an American Legion Post, the Post NumberBlank/UnknownPost 1Post 2Post 3Post 4Post 5Post 6Post 7Post 8Post 9Post 10Post 11Post 12Post 13Post 14Post 15Post 16Post 17Post 19Post 22Post 23Post 24Post 25Post 26Post 27Post 28Post 29Post 30Post 31Post 32Post 34Post 35Post 36Post 37Post 39Post 40Post 41Post 42Post 43Post 44Post 45Post 46Post 49Post 50Post 51Post 52Post 53Post 54Post 56Post 57Post 58Post 59Post 60Post 61Post 62Post 64Post 65Post 66Post 68Post 69Post 70Post 72Post 73Post 75Post 76Post 78Post 79Post 80Post 81Post 84Post 86Post 87Post 88Post 89Post 90Post 91Post 93Post 94Post 95Post 96Post 97Post 100Post 101Post 102Post 103Post 105Post 107Post 108Post 109Post 111Post 112Post 113Post 114Post 115Post 117Post 122Post 123Post 124Post 125Post 126Post 128Post 129Post 130Post 131Post 132Post 133Post 134Post 135Post 136Post 137Post 138Post 139Post 140Post 141Post 142Post 143Post 144Post 145Post 146Post 147Post 2019Waiver of Claim and Permission for Medical TreatmentI, the undersigned parent or guardian of the Delegate, In consideration of the benefits derived by my son, in the event he is a member of The American Legion Arizona Boys State to be held in Flagstaff, AZ 4 June – 10 June 2023, do hereby release and discharge The American Legion and Arizona Boys State, its officers, agents, instructors, and employees from any and all claims, demands, damages, suits, actions, or causes of action which may, can, or shall by reason of any illness or accident incurred or suffered by said son while traveling to, attendance at, or participation in American Legion Arizona Boys State from the time of his departure from home until his return thereto. I acknowledge and agree *YesNoI give permission to use pictures of delegate on Boys State website or related internet accounts *YesNoI understand that my son is insured by The American Legion ONLY for that amount not paid by family insurance, or in the case of no medical insurance. LayoutFamily Insurance Company *Policy NumberClaims Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI grant permission for my son to be medically treated by a Flagstaff Medica l Doctor should such doctor, after examination, find treatment necessary. *YesNoThis Medical Consent Form must be completed, digitall signed, and uploaded with your application in the upload area below. You may only upload this file as a .pdf file. Please download and complete it prior to submitting this application. Boys State - Medical Consent Form File Upload * Click or drag files to this area to upload. You can upload up to 2 files. This file upload location is to be used to attach your Medical Consent Form provided above. Please insure you are only saving and submitting the file as a .pdf file.COVID WAIVER AND RELEASE OF LIABILITY This COVID Release and Waiver is in addition to, and does not replace, any other releases of liability, waivers or documents that have been executed in connection with this Event. Assumption of Risk: You acknowledge that you are aware that participants in Arizona Boys State taking place at Northern Arizona University on the dates of June 4 - J u ne 11, 2022 {the "Event") are not required to prove immunization against COVID-19 and its variants {"COVID") or to wea r masks, unless required to do so by state or local guidelines, i n order to participate or attend the Event, and that certain risks associated with exposure to COVID may exist at the Event. For Parents/Legal Guardians of Minors - As the parent or legal guardian of the "Minor" Delegate by allowing the Minor to participate in the Event, and by signing this COVID Waiver and Release of Liability, I, on my own behalf and/or on behalf of Minor, am assuming all risks, responsibility and liability concerning Minor's and my health and safety and possible exposure to COVID in connection with the Event. Release: In consideration for the privilege of Minor participating i n the Event, the sufficiency of which is hereby acknowledged, I, on my own behalf and/or on behalf of Minor, agree to release and to hold harmless Arizona Boys State, Arizona Boys State's corporate and individua l sponsors, the hosting site, (university, convention center) on whose premises the Event will occur, the affiliates and brands of The America n Legion, the Arizona Boys State Foundation, Inc., a not for profit corporation, and the respective directors, officers, representatives, members, agents, employees and contractors of the preceding parties (hereinafter collectively "Releasees") from any and a ll liability, whether caused by negligence of the Releasees or otherwise, for any claim, judgment, loss, liability, cost and expenses (including, without limitations, attorney's fees and costs) arising out of or connected with associated with Minor's participation in the Event and Minor's and /or my possible exposure to COVID. I, on my own behalf and/or on behalf of Minor, hereby warrant that I have read this COVID Waiver and Release of Liability in its entirety and fully understand its contents. I, on my own behalf and/or on behalf of Minor, am aware that this document releases Releasees from liability and contains an acknowledgement of my voluntary and knowing assumption of the risk of injury, ill ness and death. I, on my own behalf and/or on behalf of Minor, have signed this document voluntarily and of my own free will. SELF-CERTIFICATION I certify the above information is true and correct according to school records: Date *LayoutStudent Signature *Clear SignatureParent Signature *Clear SignatureIF NOT PAYING ONLINE: This application, once submitted and by selecting “Pay Directly With Cash or Check” will be delivered to the email address provided in this form. Please print and send a copy of this application, together with a check made payable to ARIZONA BOYS STATE, which must be filed with The American Legion, Department of Arizona, 4701 N.19th Ave., Ste. 200, Phoenix, AZ 85015, not later than March 31, 2023. A delegate paying his entire fee (including the tuition) must pay $450; otherwise the fee is $150. Online payment includes a $5 convenience fee. I wish to:Pay Directly With Cash or Check - $ 0.00Pay Now With My Credit Card - $ 155.00Donate to the Program - $ 1.00Credit Card ProcessingCardName on CardTotal *$ 0.00Submit