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Thread: KICKIN' BASS May 15th, 2015 Potomac Tx..

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    Default KICKIN' BASS May 15th, 2015 Potomac Tx..



    PRINCE WILLIAM COUNTY SHERIFF’S OFFICE
    SPECIAL OLYMPICS OF VIRGINIA BENEFIT TOURNAMENT 2015 ENTRY FORM
    KICKIN’ BASS FISHING TOURNAMENT ON MAY 15TH, 2015
    LEESYLVANIA STATE PARK, WOODBRIDGE, VA
    CHECK IN AT 0600 AM – FISHING HOURS 0700 TO 1500
    ENTRY FEE: $50.00 PER PERSON
    $10.00 BIG FISH
    100% PAYBACK ON ENTRY FEE
    100% PAYBACK ON BIG FISH
    Max of 100 Boats
    (PLEASE PRIINT OR TYPE INFORMATION)

    NAME: __________________________________________________ ____

    NAME: __________________________________________________ ____

    ADDRESS OF BOAT OWNER: __________________________________________________

    CITY/STATE/ZIP __________________________________________________ __________

    DAYTIME PHONE _________________________ EVENING PHONE __________________

    BOAT INFORMATION: MAKE: _________________________
    MODEL: _________________________
    BOAT REG. #: ______________________
    TRAILER PLATE#: ____________________

    EMERGENCY CONTACT NUMBER: ____________________________

    RELEASE OF LIABILITY
    We the undersigned agree to release, indemnify, and hold harmless the Prince William County Sheriff’s Office and Special Olympics of Virginia and any members, sponsors, advertisers, tournament hosts or anyone working with this tournament from any damages, both property and personal death that may occur as a result of our participation in this event whether it be from our negligence or the negligence of others to the fullest extent of the law. Furthermore, we give our permission to use our pictures both still and video and any quotes to be used for promotional activities by this tournament without any compensation on our behalf. Tournament officials shall have the right to refuse any application, or to deny a confirmed application, by returning the entry fee of a previously accepted application. By signing this form, we are stating that we have read all the rules and regulations of this tournament and totally agree to abide by them. We also understand that we may be asked to submit to a polygraph exam at any time and our refusal to take an exam will result in immediate disqualifications with all entry fees, prize money and prizes being forfeited.

    _________________________ _________________________
    BOAT OWNER SIGNATURE SIGNATURE

    MAKE YOUR CHECK PAYABLE TO SPECIAL OLYMPICS VIRGINIA AND MAIL TO:

    PRINCE WILLIAM COUNTY SHERIFF’S OFFICE
    ATTENTION: KICKIN’ BASS TOURNAMENT
    9311 LEE AVENUE
    MANASSAS, VIRGINIA 20110

    PRINCE WILLIAM COUNTY SHERIFF’S OFFICE 703-792-5817 WWW.PRINCEWILLIAMCOUNTYSHERIFF’S@PWCGOV.ORG
    Last edited by Snowblind; 01-23-2015 at 07:41 PM.
    Crank That Jank!

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