Name: __________________________ Clan Name: ____________________________ Address:________________________ City:___________________ Zip:_____-____ ¤Check here if you wish to be kept OUT of the Clan MacColin Directory. ¤Male ¤Female Home Phone:(___)-___-____ Work Phone:(___)-___-____x__ ¤OK ¤Need ¤Emerg Social Security#: ___-__-____ CDL: ____________ Date of Birth:__/__/____ Email, HP Address: _________________________________ Publish: ¤Yes ¤ No Emergency Party: ___________________________________ Phone:(___)-___-____ Dr./HMO: ___________________________________________ Phone:(___)-___-____ Faire Friend:_______________________________________ Where:______________ Medical Conditions: _____________________________________________________ Drugs Used/Carried: _____________________________________________________ Drug Sensitivities: _____________________________________________________ Notes: __________________________________________________________________ Current Red Cross __/__/____ CPR:__/__/____ Other:__/__/____ (__________) By my mark I request admittance to Clanna MacColin of Gleannadoire. I offer my calp, and pledge my acceptance of the command of the chief and to his Officers, who speak with his voice. X__________________________ ______________________ ______________________ applicant.................. sponsoring member..... household I,_____________________ hereby state my intention | Registered to participate in the supervised activities of | Personal Mark: Clan MacColin. I declare that I am fully cognizant | of the dangers presented to my person and property | by said participation, and do fully and completely | assume such risks solely to myself, holding | harmless all others from liability for such damage | or injury as I may suffer thereby. Especially do I | hold harmless the Chief and Officers of | Clan MacColin. | Signed :x________________________ Date:__/__/____ |
I/We the undersigned, the Parent(s) or Legal Guardian
of ____________________ authorize His/Her participation in the activities
of Clan MacColin. In the event of injury and/or illness while I/We are
absent, the undersigned authorize Steven Gillan, Chief of Clan MacColin,
or one of his warranted Officers as the Agent for the undersigned to consent
to any emergency treatment and/or hospital care, which is deemed necessary
by, and is to be rendered under the general or special supervision of,
any physician, surgeon or qualified emergency personnel. The undersigned
also further agree to waive and discharge Clan MacColin and any of its
Officers for any and all claims, actions, demands and costs whatsoever,
which may hereafter accrue on account of, or arising from the normal and
supervised activities of Clan MacColin.
Signed :x____________________________________________________________
Date: __/__/____
Signed :x____________________________________________________________
Date: __/__/____