Fort
Rowdy Gathering Encampment
Pre-Registration Application
Name:
_______________________________________________________ _________________
Trader/Organization: ________________________________________________________________
Address: ___________________________________________________________________________
City:___________________________________State:______Zip:________
Phone:__________________Best time
to call______ E-Mail Address:_________________________
Number Adults ____ Type of Lodge:______________
Blanket Trader:__ _
Number children:____ Size of Lodge: _____________ Commercial Trader:_ __
Would you like to volunteer your skills for:
Dog Soldier:____ Medic:____ Hawk & Knife:____ Children's Game______
Please indicate any special needs. Medical or Physical Problems or
Disabilities.
Diabetes:___ High Blood
Pressure:____ Epilepsy:_____
Pacemaker:______
Other:______________
________ _
Medications:___________
_________ _____
Emergency Contact
Name: _____________________________________________________________
Phone:
_______________________Day_________________ Night ____________
Pre-registration
before September 19 2008 with
payment. Camp fee: $15.00 Traders fee: $25.00
Registration
after September 19 2008. Camp fee: $25.00 Traders fee: $35.00
Camp fees include:
firewood, water, toilet facilities and one medallion per camp.
Additional
medallions may be purchased for $5.00.
Order additional medallions ____X
$5.00 = _____
Make
check or money order payable to: The Ft. Rowdy Gathering
Mail To: Fort Rowdy Gathering P.O. Box 23 Covington, Ohio 45318
Sorry, but we cannot assume
responsibility for late, lost or misdirected checks or application.
I agree
by signing this form that The Fort Rowdy Gathering, the City of Covington, Ohio
and
Jack
Herron are not liable for any loss, damage, or injury
to me or my property during
The
Fort Rowdy Gathering. I will abide by all the rules and regulations of The Fort
Rowdy Gathering.
I will also hold harmless The Fort Rowdy
Gathering, the City of Covington, Ohio and Jack Herron for all losses resulting
from my acts or omissions or those of my minor children.
Signature: ____________________________________Date: __________________________