Check appropriate boxes on left for tournaments and on right for optional big fish pot. Add the total at bottom of page.
------Beechwood Lake, Tioga PA, Jan 16 2011...................................$100.00 ----Big Fish.$20.00
------Oneida Lake , Oswego County NY Jan 30 2011.......................$100.00 ----Big Fish..$20.00
------Kahle Lake, Clarion County PA, Feb 05 2011...........................$100.00 ----Big Fish...$20.00
------Silver Lake, Wyoming County NY, Feb 12 2011.......................$100.00 ----Big Fish...$20.00
------Lake Hapatcong, Morris County NJ, Feb 20 2010.......................$100.00 ----Big Fish..$20.00
------Lilly Lake, Luzern County PA, Feb 27 2011.........$100.00 ----Big Fish ..$20.00
------Bomoseen Lake, Castleton VT, March 6 2010............................$100.00 ----Big Fish...$20.00
$_____________________$_________= Total $ _________________
Read and sign at bottom of page. If entering as an individual, fill out and sign "Angler One". If entering as a team, both entrants must fill out the required information and both must sign at bottom of page..
Angler One Angler Two
First Name________________________ First Name_________________________
Last Name________________________ Last Name________________________
Street ___________________________ Street ____________________________
City_____________________________ City_____________________________
State & Zip________________________ State & Zip ______________________
Phone_(_____)_____________________ Phone_(_____)____________________
Email_____________________________ Email___________________________
Emergency Contact________________________________
In consideration of being allowed to participate in any way in the North East Ice Tour Tournaments, its related events and activities, I, the undersigned, being of at least 18 years of age, acknowledge, appreciate, and agree that:
The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately; and,
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS The North East Ice Tour ,their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releases"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
In addition, I hereby grant The North East Ice Tour ,their officers, officials, agents and/or employees, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity permission to use my photograph or video image in any and all publications and media, including web site entries, without payment or any other consideration in perpetuity.
I hereby authorize The North East Ice Tour to edit, alter, copy, exhibit, publish or distribute any photo, video or images. I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my photo appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.
Furthermore, I have read and fully understand all the rules and regulations of such event.
I am 18 years of age or older and am competent to contract in my own name. I have read this release, and I fully understand the contents, meaning, and impact of this release.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT , FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Angler One signature____________________________ Angler Two signature_________________________________
Date____________________________ Date____________________
Mail to: North East Ice Tour, Attn Byron Eckardt, 1438 N. River Rd, Halifax PA 17032
