Personal Information

Full Name:

Last

First

M.I.

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Home Phone:

( )

Alternate Phone:

( )

E-mail Address:

Birth Date:

Business Information

Business Name:

Address:

Street Address

City

State

ZIP Code

Primary Phone:

( )

Alternate Phone:

( )

How do you wish to be contacted? [ ] Personal only [ ] Business only [ ] Both are OK

Please print this page & bring this with you to the next meeting.

I recognize that participation in the Fishing Club is a privilege, and as consideration for this privilege, I release the club and its directors, officers, employees, and agents from any and all liability and responsibility for any injury (including but not limited to physical and economic injury) or death arising out of or otherwise related to our fishing club’s operation or activities (including but not limited to participation in club activities and transportation to and from club activities), whether or not such injury or death WAS CAUSED BY NEGLIGENCE.. I further agree to INDEMNIFY AND HOLD the CLUB and its directors, officers, employees, and agents HARMLESS against and from any and all actions, causes of actions, claims, and demands of any kind that may arise from or in connection with our fishing club’s operation or activities (including but not limited to club activities and transportation to and from club activities).