Application for membership

Membership is open to all with an interest in educating the public about the War of 1812 time period.

This application does not consider sex, race, or religion.

Name ______________________________________ Date of Birth_________________________

Address:_______________________________________________________________________________

City _________________________ State____________ Zip Code________________________________

Phone(s): Home: (____)__________________________ Work: (____)_____________________________

Fax number: _______________________________ E-mail address: _______________________________

The Second Virginia Regiment is a family-oriented organization. Please list the names and birth dates of family members who might accompany you when attending events with the Second Virginia Regiment. Each adult member must also sign at the right and assumes responsibility for the actions of family minors. (Attach additional sheets if necessary).

Name Birth date Signature

Emergencies: Include the name(s) and contact information of persons to contact in the event of an emergency:

Name:____________________Address:__________________________Phone:______________________

Please list any medical certificates or training (First Aid, etc.)_____________________________________

Which type of membership are you applying for: (Check One)

Historian____

Re-enactor____

If applying for Re-enactor Select an impression:

Virginia Militia Line ____

Virginia Militia Rifleman_____

Virginia Militia Light Infantry _____

Virginia Militia Dragoon _____

US Army Regular ____

US Sailor _____

Distaff ____

Other (specify) ______

Re-enactors requiring eyeglasses are encouraged to obtain period-appropriate eyeglasses with their prescription lenses as soon as possible or do without them during times when the Second Virginia Regiment is engaged with the public.

For your protection in case of emergency, please describe any medical information which should be available to medical personnel such as allergies, asthma, diabetes, special drugs, etc.,. This will be present in the officer’s files at events.

Dues are payable annually in January at the modest rate of $2 per person or $5 per family. Dues should be forwarded to the treasurer:

Mr. Steven Forrest

7437 Flicker Point

Norfolk, VA 23505-3113

By my signature below, I certify that I am not a member of any “hate group” that fosters prejudice, nor am I a member of any group that advocates the armed resistance to or the violent overthrow of the government of the United States. I understand that handling black powder weapons and edged weapons and cooking over an open fires may be hazardous and I agree not to hold the Second Virginia Regiment liable for injuries resulting from my participation with the Second Virginia Regiment. I have not been convicted of any crime nor subject to any court order which would prohibit me from bearing arms in any state where the Second Virginia Regiment might be involved in an event.

Applicants Signature: ______________________________________ Date: ___________________

If the applicant is at least 16 years old but not yet 18 years of age, a parent’s or guardian’s signature is required, it being understood that the that handling black powder weapons and edged weapons and cooking over an open fires may be hazardous and I agree not to hold the Second Virginia Regiment liable for injuries resulting from my participation with the Second Virginia Regiment.

Parent or Guardian’s Signature:_______________________________ Date: ______________________