Membership Application : Name ________________________ Date of Birth ___________. Spouse(if married)________________________.Children Y N______ Mailing Address ______________________________________________ Soc. Sec # ___________________ City ___________________________________ State _____________ Zip ______________
Home Telephone #______________________ Work Telephone # _____________________ Occupation _____________________________________________ Will your spouse,and children,or other family members be participating in the organizatipn ? Y N (if yes please be sure to list on "Statement of Understanding".) Which,if any,current member(s) are you acquanted with ? ____________________________________________________________ List any special talents or training that you have had _____________________________________________________________________________ Have you been convicted of a felony within the past (10) years? Y N Have you ever been addicted to any drugs or alcohol? Y N Please describe any medical problems or conditions and any physical limitations that you currently have,have had in the past,or are reocurring:______________________________________________________________________________________________________________________ Emergency Contact Information : Name of person to contact ___________________________________________________ Relationship ______________________ Address _______________________________________________________ Home Telephone __________________________ Work Telephone _____________________________ Membership dues are currently $25.00 annually per mailing address.They are due and renewable on January 1st of each year. For new members who join during the year,this amount is prorated at the following schedual::join January through April= $20.00,May through August=$15.00,and September through December the prorated amount is $10.00 Checks should be made out to-"4th.Tenn.J.C.R.C.". Read and sign the membership application and Statement of Understanding and submit these documents with proper fees and remittance to : Capt. Henry A. Ford , 228 Allentown Road, Gainesboro , Tennessee 38562 . "Note;The Membership Application & Statement of Understanding MUST be read and signed by all applicants and any family participants."
All applicants and any participating family members must read and sign this Statment of Understanding and LIABILITY RELEASE.Any applicant who is under 18 years of age is required to have a parent or guardian present at all activities and to countersign the sections that follow.. STATEMENT OF UNDERSTANDING 4th.(Murray's) tn. cavalery co.E & 4th.(nreely's) tn inf. co.F,Along with the Jackson County Re-Enactment Club is a nonprofit organization for historical and educational purposes.Through the research and application of knowledge gained by it's members,the goal of the organization is to authentically portray and present the War Between The States period and the experiences of the common soldier from the Confederate 4th.(Murray's) tn. cav & 4th. (Neelly's) tn. inf. regiments but may include other union or Confederate impressions as may be determined from time to time by orgaizational officials. By signing The Application,Statement of Understanding & LIABILITY RELEASE & Express Assumption of RISK Form , I agagree to abide by ALL rules,regulations,and guidelines of the organization and will follow the instructions of organizational officials in order to promote the safety and well being of myself and others and for the overall good of the organization. I understand that I will be placed in a probationary period and that my acceptance as a member is contingent on the fulfillment of organizational requirements. Further , I understand that I will be responsible for myself and any participating family members for the compliance of said rules.I understand that my application or membership may be revoked or voting privileges denied for any noncompliance with organizational requirements or that I may resign from the organization at any time but will forfit any dues or fees paid.I certify that the facts and information provided by me are true and by signing below , I authorize the investigation or verification of all statements made or provided by me. LIBILITY RELEASE & EXPRESS ASSUMPTION OF RISK. 1.) I hereby acknowledge that participation in the activities of this organization involves certain risk:physical exertion,simulated use of weapons,explosive materials and other such elements of these activities may result in the need for medical treatment.I choose to participate in such activities in spite of these risk and the possible absence of trained medical personnel or medical facilities being nearby.The organization does not provide any medical or liability insurance. 2.) I understand and agree that the 4th(Murray's) tn.cav &4th.(neely's) tn.inf. or the Jackson County Re-Enactment Club,nor any of their respective officers,agents,or assigns,may be held liable or responsible in any way for any injury,death,or other damages to me or my family that may occur as a result of my vountary participation in this organization's activities or as a result of the negligence of any party whether passive or active. 3.)In consideration of being allowed to vountarily participate with this organization , I hereby assume all risk to me or my family in connection with such activities for any harm,injury,or damage that may befall me while I am participating in these activities ; directly or indirectly and whether foreseen or unforeseen. I further save and hold harmless all said parties from any claim or lawsuit by me,my family,estate,heirs,or assigns arising out of my participation with said organization. 4.) I state that I am of lawfull age and legally competent to sign this instrument or that I have acquired the written consent of my parent or guardian. Further,I understand that the terms herin are contractual and not mere recital and that I have signed this instrument of my own free will. It is my intention by signing this instrument to exempt and release the 4th.(murray's)tn.cav,4th.(neely's)tn.inf.regiments and the Jackson County Re-Enactment Club and all related entities described above,from any liability or responsibility whatsoever for injury,property damage,or wrongfull death of myself or any family member,however caused and including,but not limited to,the negligence of the released parties,whether passive or active. I have fully informed myself and any family members of the contents of this instrument by reading it before I signed.I have had any questions FULLY explained to me and fully understand its content and meaning and hereby execute it by signing: Applicant Signature____________________________________________ Date___________________Parent/Guardian signature;_________________________________________ Date;__________ Child or Family Partcipant & Relationship;______________________________________________________________________________________________________________________________________ Recieved for the Organization By:____________________________________________________________ Date:_________________
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