Registration Form

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

One Response to Registration Form

  1. Mark Pike says:

    I am trying to get a hold of Patrick Landrum. I am falling in with the Texas Ground Hornets under Cody Mobley. I am already registered for the event and was unaware of this registration. My cell phone is 832-443-0220. I have alos spoken to Larry McCluney who is supposed to be the Lt. Colonel.
    Thank You,
    Mark Pike

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