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Basic information
Recruit form
Name:
First _________________________________
Middle _________________________________
Last _________________________________
Home Address:
Street or Box _________________________________
City or Town _________________________________
State or District _______________________________
Country _________________________________
Age ____ Gender _______ Race ______
Health Check up:
Please submit a health form and signed by your physician
(form is on the page )
Height _____ Weight ______ Hair _____ Eyes ______
Uniform sizes:
Coat ______ Jacket* ______ Shirt _____ Waist ______
Length _______ Shoe ______ Hat ______ Gloves _____
Sash (NCO Sgt.s and Officers) Waist __________
Weapons:
All enlisted ranks;
1861 Springfield
Bayonet
NCOs;
1860 Colt pistol
NCO sword
Officers;
1860 Colt pistol
1850 Foot Officers Sword
Accoutrements:
Waist belt __________ Cross belt ________ Cartridge box _____
Cap box _____ Buckles for belts ______ Haversack ______
Bayonet scabbard _____ Canteen ______ Knapsack _______
Cup ____ Fork Spoon Knife _____
*Unit force will try to do both sides so we may need CSA Jackets as well later.
ELF1
_____________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________
Health Form ELF2a
1. Identification
Date of Birth:
/ /
Mo.
Day Year
Gender _________
Name
Last name _______________ First ____________________ Initial ________________
Address
City ____________________
State _____________ Zip ________
Health
Accident Insurance Policy no. ______________
All Military activities require a health examination within the past 12 months by a licensed health-care
practitioner*. This includes youth and adult members participating in Re-enactment activities, Athletic competition and Camp
activities. Annually, this form is to be used by all members involved in activities requiring a physical examination
Emergency Medical Information:
Has or is subject to (check and give details):
Allergy to a medicine, food**, plant, animal, or insect toxin
________________________________________________
Any condition that may require special care, medication, or diet
________________________________________________
ADHD (Attention Deficit Hyperactive Disorder)
________________________________________________
Asthma __________________________________________
Convulsions _______________________________________
Heart Trouble ______________________________________
Contact lenses _______
Diabetes ______________ type ___________
Fainting spells ______________________________________
Bleeding disorders ___________________________________
Dentures or Bridge work ________________________________
Other Explain ________________________________________
__________________________________________________
__________________________________________________
ELF2a
______________________________________________________________________________
______________________________________________________________________________
Health Form ELF2a
1. Identification
Date of Birth:
/ /
Mo. Day
Year
Gender _________
Name
Last name _______________ First ____________________ Initial ________________
Address
City ____________________
State _____________ Zip ________
Health
Accident Insurance Policy no. ______________
All Military activities require a health examination within the past 12 months by a licensed health-care
practitioner*. This includes youth and adult members participating in Re-enactment activities, Athletic competition and Camp
activities. Annually, this form is to be used by all members involved in activities requiring a physical examination
Emergency Medical Information:
Has or is subject to (check and give details):
Allergy to a medicine, food**, plant, animal, or insect toxin
________________________________________________
Any condition that may require special care, medication, or diet
________________________________________________
ADHD (Attention Deficit Hyperactive Disorder)
________________________________________________
Asthma __________________________________________
Convulsions _______________________________________
Heart Trouble ______________________________________
Contact lenses _______
Diabetes ______________ type ___________
Fainting spells ______________________________________
Bleeding disorders ___________________________________
Dentures or Bridge work ________________________________
Other Explain ________________________________________
__________________________________________________
__________________________________________________
ELF2b
______________________________________________________________
______________________________________________________________
Health Form ELF2c
Verification Statement:
To the best of my knowledge, the information in all pages and sections is accurate and complete. I request a licensed health-care
practitioner to examine applicant, to give needed immunization, and to furnish requested information to other agencies as
needed. I give my permission for full participation in 1st USV (AR) programs, subject to limitations noted herein.
In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as
judgment of medical personnel dictates.
Parent or guardian ________________________________________________
(Must sign if applicant is 18 or younger)
Applicant's Signature _____________________________
Date signed _____/________/__________
Religious Preference:
__________________________________________________
In An Emergency Notify:
Name Relationship ____________________________________
Address ____________________________________________
City
& State __________________________________________
Home Phone (____)-________-_______
Business Phone (____)-________-_______
Personal
Physician Phone (____)-________-_______
ELF2c
______________________________________________________________
______________________________________________________________
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