QHC Registration Form

Please fill in all spaces:

Your full name
Address line 1:
Address line 2:
Town/City:
State/Province:
Zip/Postal Code:
E-mail address:

Home Phone (incl. area code):
Work Phone (incl. area code):

Date of Birth:     S.I.N.:

Medical Info:

Emergency Contact Information

Name:
Address line 1:
Address line 2:
Town/City:
State/Province:
Zip/Postal Code:
E-mail address:
Phone (incl. area code):

I would like to join:
James Rogers Company
The Kings Rangers
The Voltigeurs
The Bearn Regiment

Guest only

Once you have registered and been accepted to attend an event, you are covered for third person liability insurance. Please be sure you are covered by your personal insurance, including travel insurance, if you are attending an event away from home. Please read the attached safety information regulations. Everyone, member or guest, is expected to respect these.
“I agree to respect the safety regulations, the rights of others, and the rights of the group.”
SIGNATURE OF APPLICANT ___________________________________
NAME AND SIGNATURE OF SPONSORING MEMBER ___________________________________

Please print and mail to:
Horst Dresler
77 South Street - Woodstock, Vermont 05091 USA