Palmetto Partisan Rangers

Palmetto Partisan Rangers
Our dues are $52 a family for mounted and $26 a family for dismounted and civilians
This includes insurance.
Name________________________________________
Address________________________________________
City___________________________________________
State_________________ Zip Code_________________
Telephone_________________ Cell phone______________________
E-mail________________________________
Date of Birth: ___________ Have you ever been convicted of a state or federal Felony __
List any family members who will be participating with you:
Spouse: and date of birth: ______________________________________
Children and date of birth:______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Other: _______________________________________
Previous re-enacting experience: _________________________________________________________
_________________________________________________________
Special skills: _(Musician, cook, nurse, photographer, artist, hatter, cobbler) etc_____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
.
We ask that you give a list of medications in case medical treatment is needed and you are incoherent.
Emergency Contact: ________________________________Relationship____________
Telephone #:____________________________Cell#____________________________
Address: ________________________________________________________________________
City: __________________________________ County: _______________State: _____
Physician: ___________________________________ Telephone #: ________________
Medical Insurance Co: _________________________________________________________________
Medical Information:
Contact Lenses:_________ Eye glasses:_________ Artificial Limbs:_________
Pacemaker: __________ High blood pressure_________ Diabetic___________
Allergies:________________________________________________________