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2. Belleview Youth Fishing Derby

   City of Belleview Youth Fishing Derby - Registration/Release & Waiver Form 

3. Details

   Saturday, April 1st by Lake Lillian
   
   8:30 am Registration

   9:00 am Fishing Derby

   12:00 pm Awards & Free Community Cookout sponsored by the Belleview Police Department

5. Participant Information
7. First Name
8. Last Name
10. Age
11. Group
13. Address
15. City
16. State
17. Zip Code
19. Parent/Guardian Information
21. Name
22. Relationship
24. Phone Number
25. Alt. Phone

27. The undersigned hereby releases the City of Belleview, its officials, volunteers, and employees from any and all liabilities, claims, demands, actions, and causes of actions whatsoever arising out of or relating to any loss, damage, or injury and including death, which may be sustained by the undersigned or of any property of the undersigned while engaged in the activities of the Belleview Youth Fishing Derby at Lake Lillian in Belleview, Florida.

    This release and waiver shall be binding upon distributes, heirs, next of kin, executors, and administrators of the undersigned. In signing the foregoing release and waiver; the undersigned hereby acknowledges and represents:

    1.  Has read the foregoing release and waiver, understands it, and signs it voluntarily. The person understands that they are completely responsible for the minors they sign for that are participating in this event.

    2. Has read the attached derby rules, regulations, and safety guidelines and understands them.

    3. The Fishing Derby will be held on Saturday, April 1^st, 2023 from 9:00 am to 12:00 pm.

    4. Photos of participants and award winners may be posted on Belleview’s social media site (Facebook) and webpage.

    In Witness Whereof, the undersigned has hereunto set his or her hand and seal this day.

29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Parent/Guardian Electronic Signature
32. Contestant Name (Print)
33. Date
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

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