Round Valley Lake Blue Gill Fishing Derby
Registration Form
(Please type in the requested information)

Must be 15 years old or younger.  One entry form must be filled in for each entrant.

First Name: Last Name:  Age:

Mailing Address:

City:     State:  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip:

Home Phone: - Emergency Phone: -

Registration:  $8 or ($10 after 6/18) enclosed: $8.00 $10.00

Make checks payable to Indian Valley Chamber of Commerce

Accident Waiver and Release from Liability: As a parent or guardian of the above listed minor, I/we expressly assume all risks associated with participating in this tournament/derby and I/we hereby release Indian Valley Chamber of Commerce, Round Valley Lake Resort, the hosts, sponsors, and tournament officials from all claims or injury and/or damage incurred in connection with this tournament/derby.  I/we hereby agree to be bound by and comply with all tournament/derby rules of tournament/derby officials.

Parent or Legal Guardian:

____________________________________________________
Signature

Print this page and mail the filled-in form with signed release and remittance to: 

Indian Valley Chamber of Commerce 
P.O. Box 516, Greenville, CA 95947