ALA Oregon Girls State Application 2018

Important! Student must have their parent/guardian available to complete and sign their portion of the application below before you begin.
Both sections must be completed before the application can be submitted.
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First Name: Last Name:

Preferred Name: Email Address:

Date of Birth (mm/dd/yyyy):

Mailing Address:
Street: City:
State: Zip Code:

Home Phone: Cell Phone:
Other Phone:

School Name: School Location:

Do you participate in:
Band/ChorusDebate/SpeechStudent GovernmentSportsOther

GPA: Expected Graduation Date (mm/dd/yyyy):

Awards in School: Office(s) Held in School:

Awards, Activities, and Volunteer Activities outside of school:

Future Educational/Career Goals:

Do you have:
A Sponsoring American Legion/Auxiliary Unit that will contribute $200?

1) Auxiliary Unit Name: Post#:


2) A private sponsor who will be paying the $300? YesNo

Please indicate shirt size for ALA Oregon Girls State polo shirt (provided): SMLXLXXLXXXL

ALA Oregon Girls State Rules and Applicant Agreement:
•I am a legal resident of Oregon.
•I believe in the constitutional form of government of the United States of America and the principles for which it stands.
•I have respect for and will pledge allegiance to the flag of the United States of America.
•I understand that completing and submitting this application is not a guarantee that I will be accepted to attend Girls State.
•I understand that no applicant will be denied attendance based upon any medical infirmity, handicap, or special needs.

If accepted to attend Girls State:
•I will act safely, respectfully, and responsibly at all times, reporting violations and/or injuries or illnesses immediately to staff.
•I will abide by all Girls State rules and regulations and will abstain from possessing, using, and/or participating in the use of: alcohol, tobacco, illegal drugs, gambling, weapons or engage in any illegal activities while at ALA Oregon Girls State.
•I will conduct myself in such a manner as to bring credit to myself, my sponsor, and the community in which I live.
•I will avoid fraternization with the opposite sex.
•I will remain for the entire program, participate in all Girls State functions, and keep to the schedule.
•I will remain in the designated areas at all times. I will not leave campus or travel in a vehicle without staff knowledge and approval.
•I will safeguard the property of others, including roommates, other citizens, counsellors, staff, and the university campus.
•I will provide a report to my American Legion Auxiliary Unit of my experiences at Girls State and Girls Nation.
I hereby acknowledge the above Rules and Applicant Agreement, and agree to abide by the above rules and understand that violation of any or all of these rules is cause for being sent home, and if expelled from the program, I will be required to reimburse the American Legion
Auxiliary for fees and costs associated with the dates of my attendance in the program on per diem (per day) basis:

Applicant/Student Signature (Required)
Please sign below using your mouse.

Today's Date (mm/dd/yyyy):

To be completed by a parent or guardian.
Name of Parent/Legal Guardian: Relationship to Applicant:
Work Phone: Parent/Guardian email:
Indicate any Health Conditions, Allergies, Special Diet, etc. of Applicant:

Medications Taken by Applicant (both over-the-counter and prescription):

Alternate Emergency Contact Name:

Emergency Contact Phone Number:

Costs associated with ALA Girls State:

registration fee .....................$50

Refundable registration fee……$50
(see information packet for terms)

Replacement meal card .........$5

Parking fee (entire week) .....$10

You may also wish to bring money or debit/credit cards for the ALA Girls State Store.

Parent/Legal Guardian Permission and Acknowledgment: The applicant herein is a legal resident of Oregon and has my permission to attend ALA Oregon Girls State. She is in good physical and mental condition and may participate in any indoor or outdoor activity (with exceptions noted above). In case of emergency, The American Legion Auxiliary is authorized to secure proper medical treatment until I can be reached. Upon acceptance to the program, I understand that she must attend the complete program in order to represent that she attended ALA Oregon Girls State. The American Legion Auxiliary is permitted to confirm/deny her attendance at ALA Oregon Girls State with colleges/universities/employers, etc. without prior or further authorization. It is understood that no compensation or fees are to be paid by The American Legion Auxiliary if the applicant’s information or likeness is used to promote its programs. I acknowledge that the applicant may be exposed to topics or language of an adult nature. The applicant understands the rules and has agreed not to use and/or participate in: alcohol, tobacco, illegal drugs, gambling, weapons or engage in any illegal activities during her week at ALA Oregon Girls State. I have read the Rules and Applicant Agreement above, and hereby acknowledge and understand that a violation of any of those rules is cause for my daughter to be sent home, and if expelled from the program, I will be required to reimburse the American Legion Auxiliary for fees and costs associated with the dates of her attendance in the program on per diem (per day) basis. I agree to carry medical insurance, indicated above, throughout the duration of the 2018 Girls State program. All medications (listed above: both over-the-counter and prescription) will be given to the ALA Oregon Girls State Nursing staff upon arrival. I certify the information on this application is correct, complete, and that the applicant meets school certification requirements (below). I hereby release The American Legion Auxiliary, ALA Oregon Girls State, Willamette University, and all of their members, staff, volunteers and officers from any liability for any harm that the applicant may suffer during or as a result of participation in ALA Oregon Girls State, including but not limited to physical, emotional or psychological injuries, and I will indemnify and hold harmless the above entities from liability for any damage caused to or in the presence of the applicant.

Parent Signature (Required)
Please sign below using your mouse.

Date of Signature (mm/dd/yyyy):