Perch Lake Bass Challenge
2011 Entry Form
Captain’s Name:
____________________________________________
Mailing Address:
____________________________________________
Town/City:
Postal Code:
___________________ Phone: ______________________
Email:
________________________________________
Partner’s Name:
_____________________________________________
Mailing Address:
____________________________________________
Town/City:
Postal Code:
___________________ Phone: ______________________
Email:
________________________________________
Boat and Motor Brand:
_________________________________________________________
_____________________________________________________________
Waiver
of Claim Release and Indemnification agreement in consideration of the
acceptance of my entry in the Perch Lake Bass Challenge, it’s promoters,
employees, sponsors, organizers, host, directors, officers, and all other
organizers and affiliated organization, agencies and/or agents and assignees
and any other person assisting in this event from any claims for damages or
injuries suffered by me as a result of my participation in or traveling to or
from the event. I hereby state that I am in proper physical condition to
participate in this event and am aware that participation could, in some
circumstances, result in physical injury. I further agree to indemnify Perch
Lake Bass Challenge et. al.
(mentioned above), from any claims or damages arising out of or in consequences
of the participation or attendance by me in this event. If under the age
of eighteen, this waiver of claim, release and indemnification agreement must
be signed by a Parent or Legal Guardian.
Entry
and Acknowledgement:
Having
read the rules and regulations, I hereby submit my entry form for the
registration and enclose my entry fee. By signing this form I agree with the
rules and agree to abide by said rules.
Captain’s Signature:
________________________ Date Signed: ________________
Partner’s Signature:
________________________ Date Signed: ________________
Parent’s consent :______________________________Date
Signed:________________
Cash or cheque for $100 required with entry. Cheque
payable to John Homer
*no spots will be held without payment and signed entry form
Mail or drop off to
John Homer
P9A 2E7
Or drop off at