Consent to Medical Treatment and Hospital Services

In the event that I am a participant of the American Legion Louisiana Boys State program, to be held in Hammond, Louisiana on the campus of Southeastern Louisiana University, I 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(s), including the administration of an anesthetic, laboratory procedures, medical or surgical treatment, x-ray examination or other hospital services. Permission is also granted for minor treatment, including the use of first aid medications and over-the-counter pharmaceuticals to be given by the Boys State Staff and/or program nurse.

I understand that in the event of an emergency, every attempt possible will be made to contact the emergency contact I have provided on the Medical Information and Consent form.

I understand that my participation in Louisiana Boys State may be terminated at the discretion of the Chair of the Boys State Commission and/or the Program Staff and/or on the recommendation of a licensed medical provider if it is determined to be in my best medical or mental health interest.

Media Acknowledgement

In signing below, I acknowledge that there are many media production opportunities at LABS Program. This may include but is not limited to pictures, video, and audio taken by visiting press, Boys State staff, counselors, volunteers, and Citizens; University staff; and/or other members of the public present during the program and presented in a variety of media including print, broadcast, or online. I acknowledge and give my permission for my picture and/or name to be used regarding the LABS program.

Participation Acknowledgement and Waivers

I understand and confirm that participation in the American Legion Boys State program is voluntary and that I consent to participate in all activities in conjunction with this program. I further understand that my participation may involve risk of injury or loss, both to person and to property. I assume all risks in any way connected with said participation and I accept personal responsibility for any liability, injury, loss, or damage in any way connected with said participation.

This will further certify that I, the undersigned, in consideration of the benefits and opportunities derived as a participant of the Louisiana American Legion Boys State program to be held at Southeastern Louisiana University in Hammond, Louisiana and having activities on the Southeastern Louisiana University Campus, do hereby release and discharge the American Legion, its officers, agents, staff, employees, and program volunteers from any and all claims, demands, suits, actions, or course of action which may can, or shall have reason of illness, injury or accident incurred or suffered while in attendance of said American Legion Louisiana Boys State program, and that the provision of such insurance is my own personal responsibility.

Registration Acknowledgement

By digital signature below, I certify that I have read, agreed to, and hereby acknowledge with my signature 1) the American Legion Louisiana Boys State Counselor and Volunteer Conduct Contract, 2) background check, sexual assault, and misconduct (SAM) training, and reporting policies, 3) program and University anti-hazing policies as provided on the Louisiana Boys State website.

Finally, I do hereby certify that the information provided in the Personal and Medical Information form is true and correct to the best of my knowledge.