Participant's Name *

(Age 6-14)

First Name

Last Name

Parent/Legal Guardian *

To attend the event with the participant listed above.

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

I hereby give consent for my child listed above to participate in State Representative Dave Vellas 68th District Fishing Frenzy While every precaution will be taken to safeguard my child it is understood that I release State Rep Dave Vella and its sponsoring agents from all responsibility in case of accident or illness while participating in this event I hereby give permission to use photographs/video taken pertaining to the Fishing Frenzy Event *

Accept