Palmetto Soldiers Relief Society
Application for Membership
NAME:
E-Mail:
ADDRESS:
HOME PHONE:
CELL PHONE:
WORK PHONE:
Birthday:
SPOUSE:
Spouse’s Phone: Cell #
Children:
(names, ages, & birthdays)
Emergency Contact:
Phone: Relationship:
Insurance Company:
Group # ID #
Doctor’s Name:
Phone:
Briefly Describe any Medical Condition/Allergy, Medications, etc.
Briefly Describe special talent, skill or knowledge you are willing to share:
By signing below I agree to abide by the By-Laws, standing orders and safety regulations of the Palmetto Soldier’s Relief Association and the Palmetto Battalion in order to accurately portray the women of War Between the States Era. I will actively support and enhance the authenticity of the PSRS and the Palmetto Battalion by preserving and perpetuating Southern History and Heritage
Applicant's Signature: ___________________________________________________date______________
Unit Representative's Signature:____________________________________________date______________
Unit Affliliation_________________________________________________________________________
Please mail application and $15.00 Dues to:
Lynn Dukes
Secretary, PSRS
118 Hope Drive
Summerville, SC 29485
Your membership in a Palmetto Battalion's Unit must be verified before you may have all the privileges
of the new membership year. If you submit this form without having you Unit Rep. sign it, then it must
be varified. Please include a contact name in the field above to help us expedite this for you.
2009-2010 Unit Reps
Unit Reps:Sandy Sharpe - 15th SCVIMaria Shull - 14th SCVILouise Murray - 11 SCVISherry Key - 25th SCVIKathleen Harris - 8th SCVICarla Dorn - 13th SCVIPat Blitch - SCLALekena Ackerman - 20th SCVILee Bryant - 27th SCVILynn Dukes - Black Oak