Team Entry Form Oct 31st Club Tournament: Lake Yale @ Marsh Memorial Park Boaters Please Note: $300,000 of Boating Liability Insurance is required for all tournament boats. Please include a copy of your Boat insurance with this entry form. All boats must have fully functional live wells and meet all F.W.C. safety regulations to include kill switch.I and my boat have the proper boat insurance and safety equipment required as stated above?* Yes No Having acquainted myself with the tournament rules, I have completed this application and submit it for entry into the Tournament listed above. In signing this application, I agree to be bound by, and comply with all Tournament Rules and Regulations. I expressly assume all risks associated with this tournament and hereby release Marion County Youth Bassmasters, its Officers, the host, sponsors, Tournament Officials, and any other organizations involved in this Tournament, from all claims of injury and/or damages incurred in connection with this Tournament. I further understand and agree that the Tournament Committee reserves the right to reject my application for any reason. I hereby waive my rights and/or the rights of my child of privacy or publicity with regard to the images, programming in which I/his/hers or my/his/her likeness might appear and consent to Marion County Youth Bassmasters; and their affiliated and subsidiary companies and sponsors (and those acting under their permission or upon their authority), copyrighting, distributing, televising, cyber, internet, publishing and using in any way the audio and visual portions of any television videotape, transcript, film and photographs or pictures of me or of interviews, scenes or other sequences in which I may be included, and any reproduction thereof, anywhere at any time through any medium or media for advertising, promotion, marketing, trade, television programming or other lawful purpose whatsoever; and I shall not be entitled to receive any royalties or other compensation in connection with such use. I further understand and agree that Marion County Youth Bassmasters are the rights and property owner of these videos and photosTeam Registration***$25.00 PER ANGLER***Number of Anglers*One AnglerTwo AnglersEvent Location* Date* Month Day Year Angler #1 Name* First Last Angler #1 B.A.S.S. Number* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Age*Current Grade Level* Angler Electronic Signature* Angler #1 Parent Electronic Signature* Parent Phone*Angler #2 Name* First Last Angler #2 B.A.S.S. Number* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Age*Current Grade Level* Angler #2 Electronic Signature* Angler #2 Parent Electronic Signature* Parent Phone*Boat Captain?* Yes No Boat Captain InformationBoat Captain Name* First Last Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Electronic Signature* Mail all completed forms to Daniel Tillis 840 SE 28th AVE Ocala Fl 34471 or email completed forms to bassfshnfreak@yahoo.com. Forms and payment must be turned in at or prior to meeting scheduled before tournament in order to participate! Checks payable to Marion County Jr Bassmaster. Any Concerns call (352) 572-3148 or email bassfshnfreak@yahoo.com. Total $0.00
Marion County Youth Bassmasters