NAME: _________________________________________________ AGE: _______ DATE OF BIRTH ___________________________
CITY: __________________________________________________________________ STATE: ___________ ZIP: ________________
PARENT/GUARDIAN NAME: _________________________________________ HOME PHONE: ______________________________
EVENING/WEEKEND PHONE: _________________________________________ EDUCATION LEVEL ________________________
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: _____________________________________________________________
PARENT AUTHORIZATION AND GENERAL RELEASE FROM LIABILITY
I approve of my child's attendance at the Civil War Artillery Camp and certify that s/he is in good health and is fit to participate. I understand that there are inherent risks in this activity, which have been considered and which the participant assumes. Participant has medical insurance. 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 my child, if in the judgement of Chesapeake Artillery, Inc., it is required.
This waiver has been read and understood and is signed voluntarily by me as the legal representative for the participant.
PARENT/GUARDIAN'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.