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Chirurgeon Quarterly Report Form

Reporting Dates: March 1 June 1
September 1 December 1
Legal Name: SCA Name:
Address: City:
State: ZIP code:
Telephone Number: E-mail Address:
Membership Number: Expiration Date:
Please indicate the events at which you functioned as a chirurgeon. For those events where you were Chirurgeon-in-Charge, check the last box. If you have not submitted any event reports, please submit those reports separately on the appropriate form.
Event Name Event Date Hosting Group Chirurgeon-in Charge?
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Other things worth mentioning that happened this quarter:
Please include a copy of your SCA-membership card and first aid/CPR certificates if they expired and you renewed them since your last report! You can either snail mail them or scan a copy and send them elecronically.
Include the email address of anyone besides yourself and the Kingdom Officer who should receive this report. An example might be your Seneschal or a Baronial Officer. Separate multiple addresses with a comma.
Security Code Security Code:    
Æthelmearc is a Kingdom in the Society for Creative Anachronism (SCA), a non-profit educational society dedicated to the recreation of the Middle Ages and Renaissance.

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