Full Name:Age:

Sex:     M      F               E-mail Address:

Home Phone:

Street Address:

City:     State:              Zip:

Emergency Contacts:

1. Name:     Phone: 

2. Name:    Phone:

Yes   No    Have you ever been convicted of a felony crime?                                          Yes   No    Are you a member of any other history  organization? If so, what?

May the 137th NY add the following information to their webpage?

Yes    No   Your picture                                                                                                      Yes    No   Your Email Address                                                                                          Yes    No   Your phone number                                                                                   Yes    No   Have you read, and do you understand the by-laws of the USV  & 137th                                                                                                                                                               Yes    No    Have you received and filled out a medical form?

What impression do you wish to portray?    Military   Civilian   Musician

Member Signature                                                                Date:

Parent/Guardian Signature( if under the age of 18)                 Date