M.L.H.A.
		Mid-west Living History Association         Membership Application
	Name:________________________________________________                 Last                  First                              M.I.        Address:________________________________________________              Number                       Street                    Apt.#                     ________________________________________________              City                             State                        Zip               Phone:  ___________________   Cell:________________________ Date of Birth: ___________     E-Mail: _______________________ Primary Impression: _____________________________________________                                   Unit Name                                       Nationality Secondary Impression: ___________________________________________                                      Unit Name                                   Nationality Medical conditions: ________________________________________                                                                                          Note to Minors   All minors must have parents approval. Minors participation in certain   events will be approved on an individual basis. Parent signature:______________________________ Date:__________ By signing this I state that I will follow all M.L.H.A. rules and conduct my self in a respectful manner. Applicants Signature:_________________________     Date:___________              Make Checks/Money Orders payable to M.L.H.A for $15.00                                                                                            Mail to:                                             MLHA C/O                                        S. Dussetschleger                                           PO Box 422                                       Belton, MO 64012
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