Fill and Sign the Verification of Income and Health Insurance Form

Kingdom of Trimaris Combat-Related Activities Authorization Information Form (Print legibly or authorization will be rejected & returned)_____________________________________________ Mundane Name:__________________________________________________________________________________________ (last) (first) (mi) Address: ______________________________________________________Apt: ______ (street, P.O. Box, etc) ________________________________________________/____________________/____/________________ (City) (County) (state) (zip) Card #: _____________________ Date Received: _______________ Date Issued: _________________ Date Expired: ________________ (Official use only) Phone: (_____) ________-____________Date of Birth: ______________ E-mail: _________________________________________ (mm/dd/ccyy) SCA Name: __________________________________________________________________________ Card #: ________________ (Include titles, lord, sir, etc) (if already authorized) Shire/Barony: _________________________________________________ Household Affiliation: ___________________________ Date of Authorization: ________________ Place of Authorization: _________________________________________________ (mm/dd/ccyy) (To be completed by authorizing officials) Type of Authorization: (Check only one) Ο New (Event name/Practice/ etc….) (required for all authorizations) SCA member # Ο Renewal Ο Additional Styles _______________ Expiration Date _______________ (Check if under18) Ο Youth Area of Authorization: (check only one) Ο Armored Combat Ο Rapier Combat Ο Ranger Authorized Styles/Activities: (check all that apply) Armed combat (A/C) Ο Weapon/ Shield (W/S) Ο Two weapons (TW) Ο Two hand weapon (THW) Ο Spear (SP) Ο Combat Archery (C/A) Ο Siege Weapon (SW) Rapier Combat (R/C) Ο Rapier Only (RO) Ο Rapier Brace (RB) Ο Defense second (D/S) Ο Cloak (CL) Ο Main Gauche (R/M) Ο Schlager Only (SO) Ο Schlager Brace (SB) Ο Cut and Thrust (CT) Authorizing Officials: Print SCA and sign mundane Marshaling (M) Rangers (RG) Ο Armed Combat (ACM) Ο Archery Ranger (AR) Ο Rapier Combat (RCM) Ο Thrown Weapons Ranger (TWR) Ο Rapier/CutandThrust (CTM) Ο Combat Archery (CAM) Ο Siege Weapon (SWM) Ο Youth Combat Marshal (YCM) Ο Junior Youth Combat Marshal (JYCM) ____________________________________________________ ________________________________________________ (SCA name) (Mundane name) (Date) _________________________________________________________________ ____________________________________________________________ (SCA name) (Mundane name) (Date) Signatures for Authorization: For Armored combat, except of C/A, requires a member of the Chivalry and a warranted ACM or two member of the Chivalry. For C/A, an authorized CAM is required and a member of the Chivalry. For SW, an authorized SWM is required and a member of the Chivalry. For Rapier Combat, two warranted RCM. For Cut and Thrust, two warranted RCMs, one being a CTM. All marshal/Rangers authorizations require the signature of the Kingdom level supervisor for that discipline. A separate Authorization form is needed for each AREA of authorization, i.e. Armored combat, Rapier combat, etc. This form should be delivered to the Earl Marshal or their designated representative. For Rapier combat this form should be delivered to the Kingdom Rapier Marshal or their designated representative. For renewals, enclose a copy of old card or obtain appropriate signatures above. For NEW authorizations, enclose a copy of SCA membership card. For New and Renewal a Combat Waiver form is required. The participant and any local marshals should retain a copy of this form. Issuing Marshal: _________________________________________________________________________________________ (SCA name) (Mundane name) (Date) Ver 5.0 05/22/06 AR