Skirmish at Jeffersonville

to be held at

Historic Crab Orchard Museum & Pioneer Park, Inc

in Tazewell, VA

April 20-22, 2012

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Registration Form

Unit Name_________________________________________________

Contact Name______________________________________________

Address___________________________________________________

City____________________________State____________Zip________

Telephone___________________ E-Mail_________________________

Please check the appropriate response below:

US Infantry ________ CS Infantry _________

US Medical ________ CS Medical _________

US Signal ________ CS Signal _________

US Artillery ________ CS Artillery _________

US Cavalry mounted____ not mounted____ CS Cavalry mounted____ not mounted ___

Auth Civilians ________

Other _________ Describe:_______________________________________________

Prepared to Galvinize?__________

Horse Count ______ (The appropriate Coggins papers must be provided to event registration staff upon arrival to the event) Will pay $25.00 per horse

Cannon Count ______ (First 10 participating cannons registered receive $100 powder bounty with full weekend participation) $50 per mortar

Gun Count ______ GunType(s)_______________________________________________________________________

Comments_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Confederate Participant(s) ____ X $8 (before March 25^th)

$___________

Yankee Participant(s) ____ X $8 (before March 25^th)

$___________

Total Participants ____ Total Amount Enclosed $____________

Note: Please make every effort to register prior to March 25^th, Registration and walk on $10 at the gate. We want to be able to provide for enough materials, supplies, and food for all reenactors.

I have read and agree to abide by the rules and regulations of this event and will work with event organizers to the make this event safe and successful for all participants and spectators. In no way will I hold Historic Crab Orchard Museum & Pioneer Park, Inc., any person, staff member, volunteer, event donor, event sponsor, or event space landowner associated with this event responsible for any injury or damage that may occur to myself or my property or property of another in my possession during my visit and participation in the event.

X________________________________________________________(signature required)

Checks should be made payable to HCOM. Payment and Registration Form should be mailed to HCOM, 3663 Crab Orchard Road, Tazewell, VA 24651. Each participant is required to complete a registration form.

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