Registration Form

The Independent Rifles hosts:
“Bloody” Sixth at Shiloh
March 29-April 1 2012
An Adjunct at Cleburne’s Division’s 150^th
Shiloh

Registration  fees are non-refundable. Incomplete registration submissions will not be processed.

Name: ________________________________________________
Street Address: __________________________________________________
City:_________________________ State:__________ ZIP:______________
Phone:________________________ Email:_____________________________
Age:______________________________________________
Company Commander:_____________________________
Medical Conditions:_______________________________________________
Emergency Contact information: _____________________________________

Signature___________________________________  Date:________________

Please make out all checks and money orders to Patrick Landrum.  The address to send these forms to is:

Patrick Landrum
1509 Bunbury Drive
Thompson’s Station, Tn 37179

Registration will be $30 paid via check or money order. This will include your registration
fee for the event as well as rations. Registration ENDS March 1, 2012.