| Pumpkinvine Creek 1864 Application All applicants must apply as individuals. NO UNIT REGISTRATION. Name: _______________________________________ Address: ____________________________________________________________________ Phone: ________________________________ e-mail: ___________________________________________ Unit & rank: (Note that NCO and commissioned ranks will be assigned; all participants must be willing to serve as a private.) I would like to attend Pumpkinvine Creek 1864. I have enclosed a registration fee of $10.00. Please make check or money-order to "Pumpkinvine Creek." I wish to attend as (please circle one:) Federal (Co. E, 104th Illinois Inf.) Confederate (Co. G, 42nd Georgia Inf.) RELEASE: I the undersigned, understand and acknowledge that I will be participating in a potentially dangerous activity, Pumpkinvine Creek 1864, with concern to the use of Civil War era firearms and in the recreational use of the property for marching, entrenching and other outdoor activities. As a condition to, and in consideration of receiving the permission of the First Georgia State Line, First Georgia Regulars and the William Harris Homestead, I hereby agree and promise to assume risk and responsibility for any and all injuries, or damages due to injuries, suffered by me or caused by third parties to me, arising out of participation in the aforementioned activities. I understand that any injury, sickness or condition I may suffer from may result in medical expenses, transportation costs and lost income and that these will be my sole responsibility. I acknowledge that it is my own, sole duty to determine if my participation in these activities is safe and in my best interests. I state and agree that I have discussed the issues raised in this agreement and release with my family, next of kin and dependants. They understand that I could be permanently injured or killed. I hereby release, indemnify, and forever discharge and hold harmless: Members of the First Georgia State Line, First Georgia Regulars, William Harris Homestead and guests of the aforementioned parties from any and all responsibility, liability, claims for personal injury, legal actions or suits, damages or losses of any kind or description, both at law or in equity, arising out of, or in any way connected with, any of the above mentioned activities. Signature:___________________________________ Date: ____________________________ If under 18 years of age, signature of parent or guardian Certification: I have read and will comply with the event uniform guidelines. I understand there will be a uniform inspection on Friday, May 31, 2002. I will respect and honor the orders of officers and NCO's appointed over me. Signed: _____________________________________ Date: ____________________________ Return this form to: Robert A. Mitchell 318 W. Highland Ave. Monroe, GA 30655 |