25th North Carolina Infantry Regiment, Inc.
Application For Membership
Name:__________________________________________________________________ (Last) (First) (Middle)
Address:_________________________________________________________________
City:________________________ County:________________ State:______ Zip:________
Phone: Home:_______________________ Work:_________________________
Occupation:____________________________ Employer:__________________________
Date of Birth:_____________________
List any family members who will be participating with you in this organization:
Spouse:_________________________________________ Date of Birth:_______________
Child:___________________________________________ Date of Birth:_______________
Child:___________________________________________ Date of Birth:_______________
Child:___________________________________________ Date of Birth:_______________
Child:___________________________________________ Date of Birth:_______________
1. Are you now, or have you ever been, a member of any group that advocates or espouses the overthrow of the United States Government, Racial Superiority, White Power, Klu Klux Klan, or the obstruction of Civil Rights or the US Constitution? YES NO
If yes, please add a detailed letter of explanation.
2. Have you ever been convicted of a felony or served time in prison? If yes please provide a detailed explanation. YES NO
3. Are you aware of the cost of your equipment and the time period for acquisition? YES NO
4. Are you aware that all equipment is subject to inspection and approval? YES NO
5. Have you familiarized yourself with all 25th NC rules and regulations and agree to obey them? YES NO
6. Do you have any previous reenacting experience? YES NO
If yes, what unit(s) and years of association?________________________________________________
7. Do you have any skills/talents that you would like to share. (artist, cook, carpenter, etc.) YES NO
If yes, please explain on back of application.
I pledge and agree to conduct myself in a gentlemanly/ladylike manner at all times while representing the 25th North Carolina Infantry Inc. I understand the spirit and intent of this organization and agree to abide by all of the rules, regulations and bylaws. I further confirm that all of the above questions have been answered truthfully to the best of my knowledge.
Signed:______________________________________________ Date:_______________________
Sponsor:_____________________________________________ Date:_______________________
Medical Information Form
Note: Reenacting is a strenuous physical activity with the potential for physical injury. A copy of this form MUST be on file with the Commanding Officer for each regular, civilian and associate member and/or guest planning to participate "in the field". This is for your own protection in case of illness/injury and is NOT intended to prevent participation in activities. It is necessary to have a form on each participant in case emergency treatment is needed. Additional forms are available as needed. PLEASE PROVIDE ALL INFORMATION REQUESTED. A current tetanus shot is strongly recommended.
Name:___________________________________________ Phone:____________________________
Address:____________________________________________________________________________
Emergency Contact Information
Name:_________________________________________ Relationship:_________________________
Phone(s):_____________________________________ Usually at Events? Yes No
Address:_____________________________________________________________________________
Doctor:_____________________________________ Office Phone:____________________________
Address:_____________________________________________________________________________
Medical Information (add additional pages if necessary)
Date of last TETANUS immunization:________________________
Do You Wear: Contacts: YES NO Eye Glasses: YES NO Artificial Limbs: YES NO
Please List:
All Drugs To Which You Are Allergic/Sensitive:___________________________________________
All Prescription Drugs You Take:_______________________________________________________
All Known Or Suspected Allergies Or Sensitivities:_________________________________________
All Past Hospitalizations/Major Illnesses:_________________________________________________
____________________________________________________________________________________
Other Pertinent Medical Data (Physical Limitations, Etc,):___________________________________
____________________________________________________________________________________
Anything Else You Want Us To Know? (Special Instructions In Case Of Emergency):
____________________________________________________________________________________
____________________________________________________________________________________
In case of emergency, accident or situation where it is felt professional medical attention is needed, I hereby give my full authorization and permission to any member of the 25th NC Infantry, Inc. to take or have me taken to the nearest hospital/ER facility and arrange for my treatment. I do hereby release the 25th NC Infantry, Inc. and any individual authorizing treatment from all liability and agree to hold them harmless against all claims, losses, expenses and judgments for any loss or injury resulting from said treatment.
Signed:________________________________________________ Date:________________________
Make check payable to: 25th NC Infantry Regiment, Inc.
Complete the application....sign and date...mail in with your membership dues of $25.00...and mail to:
2nd Sgt David Patterson
428 Shope Rd.
Otto, NC 28763-8700
You will be contacted after application arrives and is processed. You will then be assigned to a Company by your geographic location and your Company POC will contact you and answer any questions you may have. You will also receive your information packet which will cover what is expected of you and the list of necessary uniform and equipment items you must obtain.
Thank You for joining the 25th NC Infantry Regiment.
We look forward to seeing you in the ranks.
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