OFFICIAL ENTRY FORM

(Please submit entry form for each person in the boat)

 The Derby runs Saturday, June 13, daylight until 2 pm.

Name  _____________________________________________________________  Age (if under 18) _____

Address ________________________________________________________________________________         

City ___________________________________ State ____________________ Zip ___________________                

Email __________________________________________________________________________________

Daytime Phone __________________________________________________________________________

PSA Chapter Affiliation (if member)________________________________________________________

Mail checks by June 8, payable to Puget Sound Anglers of Renton, or use credit card online by June 12.

Derby tickets cost $15 per person.  Free tickets to anglers 16 years old or younger, but registration form required

for each participant. 

$__________Enclosed

Print and retain an extra copy of entry form.  Mail completed entry form to PUGET SOUND ANGLERS OF RENTON, 4069 Hillcrest Ave SW, Seattle, WA 98116.  Derby tickets will be emailed to the above address. Or register online using credit card by June 12 at www.rentonpsa.clubexpress.com.

I have submitted the proper entry fee and have read and agree to the rules and regulations covering the Derby.

I understand that entry fees are non-refundable.  I agree that the Derby hosts have exclusive rights to take photographs

of myself and to use or dispose of such material in any lawful manner.  Any person who enters the Derby, or who provides assistance to Derby officials or otherwise participates in the Derby, hereby agrees to waive and release, and hold harmless the Puget Sound Anglers of Renton, its officers, directors and members, the Derby Committee, sponsors and officials, from any and all claims, actions, damages (including but not limited to the Awards Ceremony; in particular, if you agree to participate, you agree that you are responsible for your own safety.