BUCKETMOUTH BASS CLUB, INC

2017 Tournament Registration form

Wavier and Release Statement:

I agree to fully comply with all regulations and event instructions of the bucketmouth Bass Club, Inc. (the "Club")

I understand that participating in the Club's event activities is potentially hazardous and can result in serious injury or death. I am aware of and do expressly assume all risks of every kind and nature whether foreseen or unforeseen associated with participating in the Club's event activities. Without limiting the generality of the foregoing sentence I expressly assume any and all inherent risks, including but not limited to hazards caused by drowning, injury to me or the watercraft that I am in by the Club or any agent of the Club or by another participant or nonparticipant, and injury or death caused by the effects of weather including heat, humidity, lightning, wind, rain, storm and other dangerous conditions.

In consideration of your accepting this application to be a member of the Club and/or a participant in the Club's activities, I for myself and anyone entitled to act on my behalf including without limitation, my spouse, children, executor, administrator, agent-in-fact, and the like hereby, waive and release from any and all claims for injuries and damages I may have against the Club, Its officers, directors, members, agents, event sponsors and their agents and representatives caused by the negligence of any of them arising out of my participation or attendance in or caused during the course of an event sponsored by the Club.

I attest that I am physically fit and have inspected my boat and have taken all possible safety precautions to avoid injury to me and other event participants.

In further consideration of your accepting this application to be a member of the Club or a participant in a club event, I agree to indemnify, defend and protect the Club and its directors, officers, members, agents, event sponsors and their agents and representatives from any and all cost, loss or damages (including reasonable attorney fees) incurred directly or indirectly by reason of my negligent or intentional acts or any act by an invitee or guest of mine.

I give permission to the Club for the free use of my name, voice and/or picture in any broadcast, telecast, advertising promotion or account in connection with the Club or one of its events.

I understand that all 2017 event winnings totaling $600.00 or more are taxable. At the end of the calendar year a 1099 will be issued.

Boat Owner______________________________________Phone___________________

Street__________________________City_______________State________Zip________

Social Security Number__________________________________

Partner__________________________________________Phone___________________

Street__________________________City_______________State________Zip________

Social Security Number__________________________________

NYS Boat Registration Number ____________________________

Signatures:

Boat Owner: ____________________________________

Partner:_________________________________________