OFFICIAL 2002 BACKLASHERS BASS CLUB

DREAM FACTORY FUNDRAISER

TOURNAMENT ENTRY FORM

BOATER                                               NON-BOATER

NAME: _______________________ NAME: ______________________

ADDRESS: ____________________ ADDRESS: ___________________

CITY: ________________________ CITY: _______________________

STATE: _______________________ STATE: ______________________

ZIP CODE: ____________________ ZIP CODE: ___________________

PHONE: ______________________

SEND ENTRY TO: Melanie Matt, 14722 W. 94th Street, Lenexa, KS 66215
To enter at the Ramp: please call Melanie at (913) 484-1199

DISCLAIMER OF LIABILITY 

IN CASE OF ACCIDENT OR INJURY, I WILL NOT HOLD BACKLASHERS BASS CLUB OR LONG SHOAL MARINA RESPONSIBLE FOR ANY CLAIMS OF LIABILITY. I CLAIM RESPONSIBILITY FOR CARRYING ADEQUATE INSURANCE FOR MYSELF, BOAT, PASSENGER AND/OR PROPERTY.

BOATER SIGNATURE: _____________________________________ DATE: ___________