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<!DOCTYPE html>
<html lang="en">
<head>
<title>Sam Shakusky : Moonrise Kingdom</title>
<!-- bring in "Montserrat" and "Crafty Girls" from Google fonts -->
<link href="css/main.css" rel="stylesheet">
</head>
<body>
<div class="form">
Khaki Scouts of North America
Scout Registration Information
<img src="images/sam.jpg" alt="">
K.S.N.A. Form 12-987
Date:
June 5, 1964
Name:
Sam Shakusky
Address:
456 Oakdale Ave
Telephone No.
KL5-6702
Emergency Contact:
None
Does the applicant have siblings/relatives that are former or current Khaki Scouts?
None
Please list name and rank
Assigned to Khaki Scout Troop No.
55
Official use only. Do not mark boxes
<input type="radio" name="group" id="group-e">
<label for="group-e">E</label>
<input type="radio" name="group" id="group-g" checked="checked">
<label for="group-g">G</label>
<input type="radio" name="group" id="group-f">
<label for="group-f">F</label>
<input type="radio" name="group" id="group-p">
<label for="group-p">P</label>
<input type="radio" name="group" id="group-k">
<label for="group-k">K</label>
I hereby grant permission to the Khaki Scouts of North America to act in <i>loco parentis</i> with regards to my son. The organization will be held harmless in the event of accident or injury.
Herbert Billingsley
Signature of parent or legal guardian
</div>
</body>
</html>