I further consent and agree to grant Backlashers Bass Club
the full use of any name, still pictures, video and voice likenesses, and will not be
entitled to receive monies, royalties or other compensation.
OFFICIAL 2002 BACKLASHERS BASS CLUB
DREAM FACTORY FUNDRAISER
TOURNAMENT ENTRY FORM
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BOATER
NON-BOATER
NAME: _______________________ NAME: ______________________
ADDRESS: ____________________ ADDRESS: ___________________
CITY: ________________________ CITY:
_______________________
STATE: _______________________ STATE:
______________________
ZIP CODE: ____________________ ZIP CODE:
___________________
PHONE: ______________________
SEND ENTRY TO: FRANK MONTEMAYOR, 6321 WEST 57TH
TERR, MISSION, KS 66202. IF PLANNING TO ENTER AT RAMP, PLEASE NOTIFY FRANK AT
913-432-1473.
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: ___________
PASSENGER SIGNATURE: __________________________________
DATE: ___________
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