D.A.R.E. “2011” BENEFIT TOURNAMENT

APRIL 17, 2011

ENTRY FORM

(Entry Fee $120/Team; Lunker $10/Team; Parking $5)

BOAT OWNER TEAM MEMBER

Name ______________________________________ Name ______________________________________

Street _______________________________________________ Street ______________________________________________

City _________________________________________________ City________________________________________________

State ___________________ZIP_________________ State ___________________ZIP_______________

Phone # _____________________________________ Phone # ____________________________________

E-Mail _____________________________________ E-Mail ____________________________________

Boat Make __________________________________ Length _________________ H.P. _______________

Registration # _______________________________ Insurance Co. ______________________________

THE UNDERSIGNED HEREBY RELEASES AND DISCHARGES THE NORTHEAST BASS ANGLERS AND ITS MEMBERS, OFFICERS AND SPONSORS FROM ALL CLAIMS, DEMANDS, RIGHTS OF CAUSE OF ACTION, PRESENT AND FUTURE, RESULTING FROM, ARISING OUT OF, OR INCIDENT TO, THE UNDERSIGNED’S PARTICIPANTS IN SAID TOURNAMENT.

ENTRY FORM MUST BE SIGNED BY BOTH TEAM MEMBERS

Signed ____________________________________________ Signed _____________________________________

EARLY REGISTRATION: CHECKS MADE PAYABLE TO N.E.B.A. WILL BE ACCEPTED UP TO APRIL 6^th AND SHOULD BE MAILED TO:

Brian Walachy

C/O NORTH EAST BASS ANGLERS

11 Pheasant Dr

Holyoke, MA 01040

CHECKS WILL NOT BE ACCEPTED AFTER APRIL 6^TH

CASH PAYMENTS ONLY AT LAUNCH SITE (APRIL 17th – SUNDAY)

LIFE VESTS MUST BE WORN UNDER GAS POWER OPERATION

FLW RULES APPLY (along with local rules presented @ site)

For more information please call: Skip @ (413) 537-1214 or Brian @ (413) 531-4962