BoysState2008

THE AMERICAN LEGION OF KENTUCKY

P.O. BOX 2123, LOUISVILLE, KY 40201

KENTUCKY BOYS' STATE, INC.

ENROLLEE QUESTIONNAIRE

PLEASE PRINT OR TYPE

Name______________________________________________Date of Birth_______________

Last Name First Middle Month Day Year

Height_____________Weight____________Home Telephone Number ( )_____________

Ft. In. Area Code

Home Address__________________________________________________________________

Street City State Zip Code

School Name___________________________________________________________________

School Adress_________________________________________________________________

Street City State Zip Code

Father's Name____________________________________Occupation___________________

Address (If different from above)_____________________________________________

Name of person to notify in the events of illness_____________________________________________

Name and addresses of local newspapers________________________________________________________

List any honors received by you_______________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

List all extracurricular school activities in which you actively participate__________________

______________________________________________________________________________________________

Do you plan to attend college?________if so, what do you propose to study?____________________

______________________________________________________________________________________________

If you do not plan to attend college, what are your plans after graduation?___________________

______________________________________________________________________________________________

What phase of government interests you?_______________________________________________________

What problems of government interests you?____________________________________________________

What phase of problems of government would you prefer discussed at Boys' State?_______________

______________________________________________________________________________________________

How were you selected to attend Kentucky Boys' State__________________________________________

______________________________________________________________________________________________

What are your chief forms of recreation?______________________________________________________

(Over)

Are you a member of R.O.T.C., National Guard, or Reserve Unit?_______if so, which?________

List any offices of class or club which you hold__________________________________________

KENTUCKY BOYS’ STATE PLEDGE

As a citizen of Kentucky Boys’ State, I voluntarily make the following pledge:

I will obey the rules of Kentucky Boys’ State;

I will take a serious and conscientious interest in discharging my duties as a citizen of Kentucky Boys’ State;

If elected or appointed to office, I will serve that office to the best of my ability;

I will conserve and protect all properties used by me and the Kentucky Boys’ State;

I will respect the judgment of my Counselors and carry out assignments given to me;

I will write my folks at home at least three times during the week of Boys’ State;

I will make a formal report of my activities and impressions of Boys’ State to my school, sponsors and local American Legion Post, upon their request;

I will be fair and honest in all of my dealings with my fellow citizens.

Signed________________________________________

This form must accompany the MEDICAL FORM and ENROLLMENT FEE. They must be sent together to the AMERICAN LEGION DEPARTMENT OF KENTUCKY, P.O. Box 2123, Louisville, KY 40201

SPONSOR BY POST NO._____________

________________________HEALTH HISTORY______________________

Louisville, Kentucky 40201

TO THE STUDENT: Completion of this report is a requirement for admission to KENTUCKY BOYS’ STATE. All health information is confidential and will be placed on file at the Boys State official. Please read the form carefully; answer all questions on both sides of the form. Consult your parents for complete and accurate answers to all questions. The completed report must be returned to THE AMERICAN LEGION, DEPARTMENT OF KENTUCKY, P.O. BOX 2123, LOUISVILLE, KY 40201 along with the ENROLLEE QUESTIONNAIRE and ENROLLMENT FEE

1. Information on Student____________________________________________________________________

Name__________________________________________________________________________________________

(Print) Last First Middle

Social Security Number ______ _____ _____

Home Address________________________________________________________________________________

Number and Street City State Zip Code

Home Telephone Number (___)_________________Age_______Date of Birth_________________________

Area Code Month Day Year

2. Medical History – Check each numbered box below yes or no and indicate year for each yes response. If in any yes response medical condition still exists, give additional

Information by numbered response in Comments on History (back page).

Have you had the following?

Yes No Year Yes No Year

Measles________________________ __________Tuberculosis____________________________

Mumps___________________________ __________Mental Health Care______________________

Chicken Pox_____________________ __________Meningitis______________________________

Mononucleosis___________________ __________Convulsions or Seizures_________________

Poliomyelitis___________________ __________Paralysis_______________________________

Anemia or Blood Disease_________ __________Severe Headaches________________________

Heart Murmur____________________ __________Head Injury with Unconsciousness________

Heart Disease___________________ __________Stomach or Intestinal Trouble___________

Rheumatic Fever_________________ __________Ulcer___________________________________

High Blood Pressure_____________ __________Yellow Jaundice (Hepatitis)_____________

Clots in Veins__________________ __________Gall Bladder Trouble____________________

Hay Fever_______________________ __________Thyroid Disease_________________________

Asthma__________________________ __________Diabetes________________________________

Pneumonia_______________________ __________Kidney Disease__________________________

Have you had any illnesses, injuries or hospitalization not already noted? ____Yes ____No if yes, explain in Comments on History (Back page).

Have you ever had surgery? ____Yes ____No If yes, indicate date and name of operation. ______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Are you allergic to any medications? ____Yes ____No If yes, indicate medication(s):

_____Penicillin ____Tetracycline

_____Sulfa ____Other drugs(specify)___________________________________________

Are you presently taking any medication? ____Yes ____No If yes, list name of drug, dosage,

strength and frequency:_______________________________________________________________________

______________________________________________________________________________________________

(over)

Have you received a tetanus toxoid immunization within the last ten years?

____Yes ____No If yes, indicate date:_________

Year

Have you been immunized against polio?

____Yes ____No If yes, indicate date:_________

Year

Have you had a tuberculin skin test? Result: ____Pos. ____Neg.

____Yes ____No If yes, indicate date:_________

Year

Have you had a chest x-ray?

____Yes ____No If yes, indicate date:_________ Result:___________________________

Year

Have you ever lived in a household with anyone who had tuberculosis?

____Yes ____No If yes, please explain:_____________________________________________

Are you capable of doing normal exercise such as swimming, tennis, volleyball, and/or other athletic activities?

____Yes ____No if no, please explain_______________________________________________

_____________________________________________________________________________________

Comments on History from Front Page. Please identify each number of yes response.

(Use extra sheet of paper if necessary.)

____________________________________________________________________________________

3. Name of Personal Physician_______________________________________________________

Last First

Physician’s Telephone Number ( )_____________

Area Code

4. Information On Parent/Guardian

Person to be notified in case of illness_________________________________________

Last First M.

Relationship to student ____Parent ____Guardian ____Other___________________

Home Address________________________________________________________________________

Number and Street City State Zip Code

Home Telephone ( )______________ Work Telephone ( )_____________

Area Code Area Code

5. Certification

I certify that all answers are true and correct to the best of my knowledge.

___________________________________________ ___________________

Signature of Student Date

Medical Consent – For Minors Only (Under 18 years of age)

I hereby consent, to having qualified medical personnel render to my son or daughter emergency treatment and medical and/or surgical care deemed necessary to his or her health and well-being. I grant permission for the hospitalization of my son when necessary for executing proper medical care.

_____________________________________________ ____________________

Signature of Parent Or Guardian Date