Perch Lake Bass Challenge Sept 4, 2016 Entry Form
Captain’s Name: ____________________________________________
Mailing Address: ____________________________________________
Town/City: ____________________________ Province: ____________
Postal Code: ___________________ Phone: ______________________
Email: ________________________________________

Partner’s Name: _____________________________________________
Mailing Address: ____________________________________________
Town/City: ____________________________ Province: ____________
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: ________________

Parents’ consent: ______________________________Date Signed:________________

Cash or cheque for $150 required with entry. Cheque payable to John Homer
* 2015 anglers have until noon Sept 14, 2015 before opening up to public
*no spots will be held without payment and signed entry form
* The young angler Atikokan Bass Classic spot does not carry over to future years

Mail or drop off to
John Homer
1100 Victoria ave NFort Frances, ONP9A 2E7

Or drop off at
126 Sykes St Atikokan ON