1Students Information

2Interests/ Agreements

3Parental Consent / Medical Information

POSTS: Cost is $225 made payable to PA American Legion

Send a check along with the completed application, including all signatures, to:

PA American Legion
Attn: KBS
PO Box 2324
Harrisburg, PA 17105

If you have any questions about completing this application, please e-mail the staff at kbsapplication@gmail.com. For questions about the KBS program, e-mail the KBS Program Dean, Carl Will, at carl.j.will@gmail.com, or (570) 242-5292; or contact the KBS Chairman, Doug Reighard at (814) 615-5431 or doug.reighard@gmail.com, or KBS Sr. Director J.W. Weedon Sr. (717) 729-0335.

Sponsoring Post's Information

Post Number

District Number

Post KBS Contact

Name and Phone or E-mail

Student's Personal Information

Name(Required)

First Middle Last

Prefer to be called

Date of Birth(Required)

MM slash DD slash YYYY

Street Address(Required)

City(Required)

Pennsylvania County of Residence(Required)

State(Required)

Zip Code(Required)

High School

If Home Schooled, enter "Home School"

Student's Email(Required)

DO NOT USE YOUR SCHOOL EMAIL

Student's Mobile Phone(Required)

Parent's Email(Required)

Different from the student's

Parent's Mobile Phone(Required)

High School grade you will have completed by June 2024(Required)

Tee Shirt Size(Required)

List your Activities, Work and Leadership Experience.(Required)

Summarize salient points here; attach your additional info on a separate page.

PA Voting Districts

PA House District(Required)

PA Senate District(Required)

US Congressional District(Required)

Find the districts for your home address at: http://goo.gl/QmGnM Please ensure you put the correct district number in the correct blank!

Outside Interests

Check the KBS activities you are interested in

Honor Guard

Running for Office

Media Program

Playing in the Band

Intramural Sports

Operating a Business

Check career fields you are interested in

Arts & humanities

Business & financial

Education

Government & political

Health care

Law

Military

Non-profit

Science & technology

Other

Specify your career interest.

Explanations of your interest in KBS activities. Your responses to these activities are not binding. They are for our planning.

Honor Guard

We honor the American flag at every morning and evening assembly. The Honor Guard, comprised of four or five volunteer KBS citizens at each ceremony, presents and retires the American flag every morning and evening. It is a task of honor, and many of the citizens volunteer to participate.

Media Program

KBS operates a media program that reflects the role that newspapers and television play in a democracy. The Citizens Voice is a daily newspaper published by the KBS citizens and KTV is a television program, also run by KBS citizens, that informs and entertains all the State of Keystone citizens every evening.

Operating a Business

For entrepreneurial citizens, the opportunity to establish and operate a business during the week is offered at KBS. The success of the businesses in each city contributes to the standing of the cities in their daily competition for Honor City.

Samsung Scholarship

An explanation of this scholarship for descendants of honorably discharged veterans and its eligibility requirements are provided at https://www.legion.org/scholarships/samsung. On that same page is a link to Samsung FAQ’s, and a link to the 2024 application that will be available on or after 1 Jan 2024. After final submission of your Samsung application online, bring a printed copy of it to KBS registration on 16 June 2024. Recommendation: make your final online submission by 12 June. In 2017, high traffic volume caused the website to crash two days before the deadline.

I plan to apply for the Samsung Scholarship(Required)

Yes

Citizen Agreement

Check the box to agree(Required)

I am making application to attend KBS to enhance my education and to further prepare me for life. I understand KBS is not a camp, but rather an educational process. I make this application of my own free will and will abide by all rules and guidelines of KBS. I understand that The American Legion and/or another sponsor will have paid for my attendance and the money is not refundable. If I am unable to attend I will notify the sponsor as far in advance as possible.

Citizen Signature

Date

Parent/guardian Consent, Permission & Release Statement

Check the box to agree(Required)

In consideration of instruction and training to be given to the child listed above as a citizen of the Department of Pennsylvania American Legion Keystone Boys State (ALKBS) to be held June 16-June 22, 2024 at Messiah University, I hereby give consent for him to participate fully in all planned activities, including a field trip to Harrisburg scheduled as part of the program. We release and discharge The American Legion, Department of Pennsylvania, and/or ALKBS, its officers, staff and counselors from any and all claims, demands, damages, suits, actions, or causes of action which we may, can or shall have by the child listed above while in attendance at Keystone Boys State, no matter how caused or occasioned, including travel to and from home to Messiah, PA. It is further understood that said son’s individual, medical or special needs are explained in MEDICAL INFORMATION on the form to be submitted to KBS at time of registration on 16 June 2024 at Messiah University and that he will participate in all phases of the program. I also give permission for him to be photographed during participation in KBS. I understand the photos may be used to promote the program in future years.

PARENTS: YOU ARE RESPONSIBLE TO REIMBURSE THE LEGION POST IF YOUR SON IS A "NO SHOW" TO KBS

Parent/guardian Signature

Date

Parental Consent To Medical Treatment And Hospital Services

Students Full name(Required)

Check the box to agree(Required)

This will certify that we (I), the undersigned parent (s) or guardians (s) of the student listed above do, hereby consent and grant permission, should the necessity of medical care arise, to the furnishing of medical treatment and hospital services as ordered or recommended by a qualified attending physician, including the administration of an anesthetic, laboratory procedures, medical or surgical treatment, x-ray examination or other hospital services.

Name of Father or Guardian

Name of Mother or Guardian

Signature of Father or Guardian

Signature of Mother or Guardian

Father or Guardian Address

Street Address Address Line 2 City State ZIP Code

Mother or Guardian Address

Street Address Address Line 2 City State ZIP Code

Father or Guardian Phone Number

Mother or Guardian Phone Number

Emergency Medical Information

Check any/all conditions listed below

Allergy to a medicine, food, plant or insect bites

Epilepsy

Lung Trouble

Hepatitis

Asthma

Convulsions

Heart trouble

Diabetes

Fainting Spells

Bleeding Disorders

Other

Explain(Required)

Date of last Tetanus Immunization(Required)

MM slash DD slash YYYY

Does the citizen take medicine daily or have special care?(Required)

If yes, please explain and list all prescription drugs:(Required)

Emergency Medical Contacts

Other than Parents or Physician

Name(Required)

Relationship(Required)

Home Phone

Business Phone

Mobile Phone(Required)

Primary Care Doctor(Required)

Office Phone(Required)

This field is for validation purposes and should be left unchanged.

American Legion

Membership Links

District Standings

Legion Family Standings

Students & Youth

Community

Emblem Sales & Veteran Support

Keystone Boys State Registration

POSTS: Cost is $225 made payable to PA American Legion

Sponsoring Post's Information

Student's Personal Information

PA Voting Districts

Outside Interests

Honor Guard

Media Program

Operating a Business

Samsung Scholarship

Citizen Agreement

Parent/guardian Consent, Permission & Release Statement

Parental Consent To Medical Treatment And Hospital Services

Emergency Medical Information

Emergency Medical Contacts

Membership Links

District Standings

Legion Family Standings

Students & Youth

Community

Emblem Sales & Veteran Support

Keystone Boys State Registration

POSTS: Cost is $225 made payable to PA American Legion

Sponsoring Post's Information

Student's Personal Information

PA Voting Districts

Outside Interests

Honor Guard

Media Program

Operating a Business

Samsung Scholarship

Citizen Agreement

Parent/guardian Consent, Permission & Release Statement

Parental Consent To Medical Treatment And Hospital Services

Emergency Medical Information

Emergency Medical Contacts

PA Legion Notices Receive Email Notices From The Department