This is the OLD version of the Northshield web site, please use the new one as this information IS outdated!

Chirurgeon Report

This form will be submitted to the Kingdom Chirurgeon.

This report is for (mark one):
December to February due March 1
March to May due June 1 All required to report.
June to August due September 1
September to November due December 1 - Domesday All required to report.

Legal Name:

SCA Name:

Address:

City:

State:

Zip Code:

Telephone Number
(with area code):

E-mail address:

Membership Number:

Membership Expiration (mm/dd/yyyy):

Group Affiliation:

Other Affiliation:

Local Officers: If your group isn't listed in the Group Affiliation menu, select "Not Listed" and type your group's name in Other Affiliation. Otherwise, select your group and leave Other Affiliation blank.

Current Status:
Chirurgeon-in-training
Chirurgeon
Mentor-Chirurgeon

Certifications and expiation dates:
First Aid:

CPR:

Check if you are sending updated certifications through the mail.

I have been CiC at the following events (event name, group and date):

I have worked as a chirurgeon at the following events (event name, group and date):

Incidents that you feel need special notation:

Questions/Queries/Comments/Concerns: