Boys State Counselors Confidential Personal Information Form Maryland Page 2
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2Present Illnesses
__________________________________________________________________________
Past Illnesses __________________________________________________________________________
Do you have any physical limitations that would limit any area of activity
__________________________________________________________________________
__________________________________________________________________________
The following information is requested in accordance with American Legion Policy.
V.
For those who will be involved in a public way sharing or teaching
as advisor or role model for American Legion Boys State youth:
A.
Are you an American Legion member in good standing and able to
participate fully in The American Legion Boy State Program?
__________ YES
_________ NO
If no, please explain:
______________________________________________________________________________
______________________________________________________________________________
B.
Have you been terminated from any service due to suspected child
Abuse, sexual abuse, or criminal activity? _______Yes
________ NO
If yes, please explain
_______________________________________________________________________________
_______________________________________________________________________________
VI.
Have you ever had your volunteer or paid services terminated at the initiative of any other organization,
school, agency or institution? ___________ YES __________ NO
If yes, please explain
_____________________________________________________________________
VII.
As a further commitment to my individual involvement in the Department of Maryland Boys State
Program,
I hereby agree to abide by the stated and voted upon position of the staff on two occasions, that the staff
will abstain from the use of any alcoholic beverages during their attendance with the Program at Washington
College in Chestertown, Maryland
Signature _________________________________________________
If I feel I am unable to abide by this commitment, I will not attend the Program and will so advise
Department Headquarters or the Boys State Director immediately so that a replacement may be nominated
to fill my position.
The information I have given in this agreement is accurate. I will serve as a counselor to the best of my ability in
accord with the policies and regulations of The American Legion, Department of Maryland, Inc.
SIGNATURE ___________________________________________ DATE ___________________
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