The Battle of Blacklick Creek

Civil War Encampment and Re-enactment

at Civic Park
in Reynoldsburg, Ohio

June 24, 25 & 26, 2011

REGISTRATION FORM
Registration Fee required for Adult Participants
Registration Fee $7.00 per Adult Participant (16 years or older)
must be received on or before June 17, 2011
Late Registration Fee $10.00 per Adult Participant received after June 17, 2011

NAME (Please Print) ____________________________________ RANK ______________________________

UNIT NAME______________________________ COMMANDING OFFICER __________________________
STREET ADDRESS _________________________________________________________________________
CITY __________________________________________ STATE _________________ ZIP _______________
PHONE (Home) __________________(Cell) _________________ (Email) ______________________________
(Please Check) FEDERAL (___) CONFEDERATE (___) SUTLER (___) CIVILIAN (___)
How will you be participating this year? (Please Circle) CSA Infantry USA Infantry
CSA Cavalry US Calvalry (Mounted or Dismounted) Civilian Medical
ARTILLERY: CSA USA TYPE ______________________________________________________
EMERGENCY CONTACT _____________________________________ PHONE ________________________
How many years have you attended this event? ______________________________________________________
TENTAGE: WEDGE (A) #_______ WALL #_______ SHELTER #_______ SIBLEY # _______
SUTLER: TENT SIZE __________LONG __________WIDE
MODERN TENTS # _____ MODERN CAMPERS # _____
SEPERATE REGISTRATION FORM IS REQUIRED FOR EACH PERSON.

Enclose registration fees; make checks payable to Society of Civil War Surgeons. Please complete and return this
registration form (postmarked) by June 17, 2011 to: Robert Mergel, Event Co-ordinator, 6448 Red Fox Court,
Reynoldsburg, OH 43068 .

Souvenir Tee Shirts available for $15.00. Pre-order only. Circle preference and size.
Shirt with artwork on front and back. Shirt with only USA on front. Shirt with only CSA on front.
Small Medium Large X-Large XX-Large XXX-Large
Lions logo appears on picture but will not appear on the souvenir tee shirts.
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STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________

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RANK ___________________________________________________________________________________
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CITY ___________________________________________ STATE ___________ ZIP __________________

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RANK ___________________________________________________________________________________
STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________

NAME (Please Print) _______________________________________________________________________

RANK ___________________________________________________________________________________
STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________

NAME (Please Print) _______________________________________________________________________

RANK ___________________________________________________________________________________
STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________

NAME (Please Print) _______________________________________________________________________

RANK ___________________________________________________________________________________
STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________

NAME (Please Print) _______________________________________________________________________

RANK ___________________________________________________________________________________
STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________

NAME (Please Print) _______________________________________________________________________

RANK ___________________________________________________________________________________
STREET ADDRESS _______________________________________________________________________
CITY ___________________________________________ STATE ___________ ZIP __________________