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Directors
President Gregory Rivero
Treasurer Scott Hase
Secretary Dale Derbidge
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2015 ELY ROTARY CLUB

ICE FISHING DERBY

JANUARY 24, 2015

8:00 A.M. TO 3:00 P.M.

CAVE LAKE STATE PARK

                                                                                                                        Application Number:____________________

Name:                                                                                                                                                                         

Mailing Address:                                                                                                                                                         

City:                                                                                                      State:                           Zip                              

Phone Number:                                                                                                                                                           

Email Address:                                                                                                                                                           

Date of Birth:                                                                                                                                                              

If under Age 12: Age:                    NV Fishing License Number:                                                                                

Parent Name:                                                                Parent Phone Number:                                                                       

 

Early Entry Fee: $ 45.00       After January 10th:  $55.00

Entry Fee Paid: Cash                                                                 Check No.                             

 

Make checks payable to: Ely Rotary Club

 

Mail to:            Ely Rotary Club P.O. Box 151827 Ely, Nevada 89315

 

By entering this contest, I acknowledge that I have read and agree to follow and comply with all applicable laws,

regulations, and contest rules.

 

RELEASE OF CLAIMS

For and in consideration of being allowed to participate in the ELY ROTARY CLUB ICE FISHING DERBY being undertaken at Cave Lake State Park, White Pine County, State of Nevada, and further realizing that I am participating in an activity for which I may be injured, I on behalf of myself, my heirs, and assigns, do hereby release and forever discharge the ELY ROTARY CLUB and it’s principals, agents, representatives, and insurance carriers, if any, from any and all rights, claims demands, damages, or causes of action, of any kind, known or unknown, existing or arising in the future, resulting from any participation in the above described activities which injuries and/or death may arise in the future from an accident which may occur in connection with the above  activities.

 

Dated this                     day of                                                                         , 20      .

 

                                                                                                                                                                          

                                                                                         Participant

 _________________________________

       Signature of Parent or Guardian if participant

     is under 18 years of age.

 

Keep a copy of the rules.

Copy this Entry Form

Submit a separate form

for each Applicant

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Service Above Self

We meet Thursdays at 12:15 PM

Jail House Motel & Casino

211 5th St.
Ely, NV 00000
United States

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Welcome to our Rotary Club! 

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