(Please type or print all information)
Important: This application is not complete without all sections filled in and the necessary signatures obtained. Address all applications and correspondence to: YOU MUST HAVE COMPLETING YOUR JUNIOR YEAR TO APPLY FOR LITTLE RHODY GIRL STATE
American Legion Auxiliary Girls State c/o Lorraine Boucher, 104 Buckeye Brook Rd, Charlestown, RI 02813
PART 1: APPLICATION boucherlorraine466@gmil.com
Girls Full Name: ___________________________________________Age:________________
Date of Birth: ______________________________Place of Birth: _______________________
Phone: ______________________________Email: ___________________________________
Street Address: _______________________________________________
City: _______________________State: ________________________________Zip:________
Why should you be considered for participation in this year’s American Legion Auxiliary Girls State Program?
Name of School: ________________________________________ Grade: _________________
School Mailing Address: _________________________________________________________
Name of School Principal: ______________________________________________________ List school or class offices you hold or have held in high school:
1. ____________________________________ 3. ______________________________
2. ____________________________________ 4. ______________________________
List activities you have participated in while in high school:
1. ___________________________________ 3. _______________________________
2. ___________________________________ 4. _______________________________
College or University you plan on attending: ________________________________________
What profession are you currently considering? ______________________________________
Name of Newspaper in Home City or Town: _________________________________________
Do you have any physical disabilities we should be aware of?
_____________________________________________________________________________ _____________________________________________________________________________
__________________________________________
Considering that the shirts tend to run small what size shirt would you need? (Please check one)
Small ___ Medium ___ Large___ X Large ___ 2XL ___3XL___4XL____
END OF PART 1
PART 2: CERTIFICATIONS
Name: _____________________________________________________________________
School: ______________________________________________________________________
Date of Birth: ________________________________________________________________
You should be fully aware of the fact that the Girls State Program is devoted to functional citizenship training for potential leaders in various communities of our State, and that your admission to Girls State depends upon your school record, character, and qualities of leadership.
Do you pledge to cooperate and participate in the activities and to abide by ALL Girls State rules and regulations?
_____________________________
(Girls Signature)
Principal’s Endorsement
As Principal of ____________________________________________School, I recommend the above-mentioned student from our Junior Class be accepted into Girls State because of her character, leadership qualities, and interest in Government.
____________________________________________
(Principal’s Signature)
END OF PART 2
PART 3: Health Certification
NOTE: The health certification below is a required part of this application. Please have it signed by a physician and return with this application.
To the Director of Girls State:
This is to certify that I have examined _______________________________and find her to be in good physical condition, able to take part in the usual recreational activities and free from contagious diseases.
Signed______________________________
Physician
END OF PART 3
PART 4: RELEASE OF LIABILITY
ST. ANDREWS SCHOOL, BARRINGTON Date: ____________________
I hereby consent to the participation of ____________________________________ in the Girls State program at St Andrews School in Barrington Rhode Island.
I hereby release the sponsors of the American Legion Auxiliary Girls State program from any and all liability which may arise due to accident, sickness, supervision or any other cause. It being understood, all participants will be closely supervised day and night by adult personnel who are skilled in their work area.
Health Insurance Policy ______________________________________________________
TRANSPORTATION:
The Girls should arrive at 3:00pm on Sunday June 17th 2018at St Andrews School, 63 Federal Rd Barrington RI 02806. The Girls will gather in the main parking lot and once checked in will be escorted to their assigned room.
I understand that transportation to and from St Andrews School on Thursday June 20nd
2019 for the State House visitation part of the program will be provided by the Girls State committee.
We ask that parents drop off student on Sunday and pick up student after graduation on Friday June 12th 2019.
_____________________________________
Signature of parent/guardian
END OF PART 4
PART 5: Health and Contact Information
Girls Name _________________________________________________________
Emergency Phone Numbers
In the event of a medical emergency, the following people and emergency medical personnel should be contacted:
Contact 1: Name: ________________________________________________
Phone Number: ________________________________________
Email: ______________________________________________
Relationship to participant: _____________________________________
Contact 2: Name: ________________________________________________
Phone Number: ________________________________________
Email: _________________________________________________
Relationship to participant: _____________________________________
Doctor: Name: ___________________________________Phone: _______________________
Insurance Carrier & Medical ID #: _____________________________________________
___________________________________________________________
Medication taken: ______________________________________________________
Allergies: ______________________________________________________________
____________________________________________________________________
END OF PART 5
PART 6:
PARENTAL CONSENT FORM
The following parental responsibility statement is to be executed by the parent, stepparent, or legal guardian where participant is a minor under the age of 18.
AUTHORIZATION AND RELEASE OF LIABILITY
KNOW ALL WOMEN BY THESE PRESENTS: That the undersigned gives permission for my minor child, stepchild, or ward, _______________________________, to utilize facilities and equipment at St. Andrews accepting fully any liability which might arise from the minor's actions. I further acknowledge that St. Andrews does not provide any liability coverage for the minor against claims, which may arise from use of said facility and equipment. Furthermore, the undersigned, in consideration of the permission extended to my minor by St. Andrews through its officers, agents and employees to use said facility and equipment, do for myself, my heirs, executors, administrators and assigns remise, release, and forever discharge St. Andrews and all of its officers, employees and agents from any and all claims, demands actions or causes of action on account of death, injury or property damage which may occur whether occasioned by the negligence, wrongful acts or omissions of said officers, personnel, agents, employees, or otherwise incurred by reason of said use, and further do indemnify and hold harmless, St. Andrews and all of its officers, employees and agents against any and all claims, demands, actions or causes of action on account of death, injury or property damage which may occur whether occasioned by the negligence, wrongful acts omissions of said officers, personnel, agents, employees, or otherwise incurred by reason of said use.
In case of accident or illness, permission is hereby granted to St. Andrews, operating through its officers, agents and employees, to authorize such medical treatment or hospitalization as may be required as a result of the use of the aforementioned facility and equipment at no cost to St Andrews School, its officers, agents and employees.
I further agree that I will require said minor to abide and strictly adhere to all rules and regulations concerning the use of said facility equipment.
_________________________________________________SIGNATURE OF PARENT/STEPPARENT/GUARDIAN
DATE________________
______________________________________________________
PRINTED NAME OF PARENT/STEPPARENT/GUARDIAN
END OF APPLICATION