NAME: _________________________________________________ AGE: _______ DATE OF BIRTH ___________________________
CITY: __________________________________________________________________ STATE: ___________ ZIP: ________________
HOME PHONE: ______________________________ EVENING/WEEKEND PHONE: _________________________________________
HIGHEST EDUCATION LEVEL COMPLETED (circle one) 11 12 College Graduate Grad. Schl.
HEIGHT _______ WEIGHT _______ PHYSICAL HEALTH AND CONDITION ___________________________________________
EMERGENCY MEDICAL AND INSURANCE INFORMATION:
HEALTH INSURANCE COMPANY ____________________________________________ POLICY NO. _________________________
PERSON TO CONTACT IN CASE OF AN EMERGENCY: _______________________________________________________________
EMERGENCY PHONE NUMBER: _____________________________________________________________
GENERAL RELEASE FROM LIABILITY
I certify that I am at least 18 years of age, that I am in good health and that I will follow the instructions of the Chesapeake Artillery, Inc. or its agents. I understand that there are inherent risks in this activity, which have been considered and which the participant assumes. I certify that I have medical insurance as listed above. I agree to hold harmless The Chesapeake Artillery, Inc. and its agents from claims or damages due to injury to person or property caused by act or failure to act of Chesapeake Artillery, Inc. I consent to emergency treatment for myself, if in the judgement of Chesapeake Artillery, Inc. it is required.
This waiver has been read and understood and is signed voluntarily by me.
APPLICANT'S SIGNATURE _________________________________________________________________DATE:_______
MAKE CHECKS PAYABLE TO: CHESAPEAKE ARTILLERY, INC.
MAIL APPLICATION TO: CHESAPEAKE ARTILLERY, INC.
7811 FLINT HILL ROAD
OWINGS, MD 20736
Upon receipt of this application and the required deposit, the participant will be sent a complete list of uniform and personal items needed for camp. A list of merchants who provide excellent quality uniform items will be included with that mailing.