2015 ELY ROTARY CLUB
ICE FISHING DERBY
JANUARY 24, 2015
8:00 A.M. TO 3:00 P.M.
CAVE LAKE STATE PARK
City: State: Zip
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 .
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