Boys State Counselors Confidential Personal Information Form Maryland
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2MARYLAND AMERICAN LEGION BOYS STATE
THE WAR MEMORIAL BUILDING
BALTIMORE, MARYLAND 21202
BOYS STATE COUNSELORS CONFIDENTIAL PERSONAL INFORMATION FORM
The following information is needed to complete the process for your being
involved as an American Legion Boys State Counselor.
The information is
considered confidential and will not be shared with anyone except those
leaders who need it to fulfill their responsibility in the area of service in
which you will be involved.
Complete the application in its entirety.
Print or type.
Return the
completed form to Director, Roger W. Butt, War Memorial Building,
101 N. Gay Street, Baltimore, Md. 21202.
Please mark CONFIDENTIAL on the
envelope.
I.
PERSONAL INFORMATION
NAME: __________________________SS#_________________ DOB__________ E-MAIL_________________
ADDRESS: ____________________________________ STATE __________ ZIP _________
Next of Kin to be contacted in case of emergency:
NAME: __________________________ SS# _________________ DOB __________
ADDRESS: ____________________________________ STATE __________ ZIP _________
PHONE: (HOME) ______________________ (WORK) ______________________________
Name of American Legion Post: __________________________________ POST NO _______
II.
EDUCATION (circle the highest level of education completed)
Elementary School
High School
Associate
College Graduate
Other (please explain)
__________________________________________________________________________________
Major in college/graduate school:
___________________________________________________________________________________
Other background that you feel useful to the Boys State Program:
_____________________________________________________________________________________
III.
HEALTH INSURANCE INFORMATION
Insurer: ____________________________ Policy # ___________________________
Policy Holder _______________________ Cert. # ____________________________
Employer __________________________ Group _____________________________
Plan Administrator ___________________ Phone # _____________________
Address _____________________ City ______________ State ______ Zip________
Military ID # __________________
IV
MEDICAL HISTORY
Physician’s Name _____________________________ Phone # _____________________
Medications you are currently taking
__________________________________________________________________________
Allergies To Medications or Other
__________________________________________________________________________
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