Registration Form www.VaBoysState.

org Delegate Registration

Registration 16-_ _ _ District No. 01-16 Post No. 364

A. Unit/Post Contact Information:

Name Jessica Wangner
E-mail jwangner@yahoo.com

B. Boys State Delegate Information:

First Name Middle Name Last Name

High School
yes or no
Age as of 16 June 2024 Date of Birth ROTC Member
Your Address
City State VA Zip Code
Home Phone Your Cell Number
Your E-Mail

C. Emergency Contact - Parent or Guardian:

Name
Phone No. 2nd Phone No.
Emergency E-Mail

D. Sponsoring Organization: (ALA Unit/AL Post, High School or Other sponsor who is responsible for selecting the delegate)
Sponsor American Legion Post 364
Contact Person Jessica Wanger /Fred Bullock
Sponsor Address 3640 Friendly Post Lane
City Woodbridge State VA Zip Code 22192
Phone No. (Post) 703-494-4304
E-Mail jwangner@yahoo.com

Please verify that all the information is correct before submitting.