ANCLOTE KEY ANGLERS, Inc
MEMBERSHIP APPLICATION:
Print & Complete Application and mail to: 3186 Charter Club Dr., Unit C Tarpon Springs, FL 34688
Make Checks Payable to-- Anclote Key Anglers, Inc.
1YR membership fee, to be renewed annually. - Individual $30.00 - Family $40.00
Name: _____________________________________ Spouse Name: _____________________________
E-Mail address:______________________________________@__________________________________
Mailing Address: ____________________________________________________________________
City: ____________________________________ State: _______ Zip: ________________________
Phone: Home: (_____) ___________________ Business: (_____) ____________________________
Fax: (_____) ____________________________ Cell: (_____) ________________________________
Business Membership, please include business name: ______________________________________
Boat: Name: _______________________________ Make: __________________ Length (ft): ______
Family membership: Please list minor children below:
Name: _____________________________ Age: ____ Name: _______________________ Age: ____
Name: _____________________________ Age: ____ Name: _______________________ Age: ____
Name: _____________________________ Age: ____ Name: _______________________ Age: ____
Are you a member of any other Angling Associations/ Clubs/ Etc?
Yes: ____ No: ____ If yes, please name: __________________________________________________
Call name for VHF Contact: ____________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------
’ I would NOT like to receive club news via e-mail.
Please circle size for free membership T-shirt: S M L XL 2XL 3XL
Please check areas that you would be interested in volunteering:
’ Membership ’ Prizes & Trophies ’ Photography/ media ’Charities ’Advertising
’ Newsletter ’ Activities/ Events ’ Tournaments (’ Inshore/ ’ offshore) ’ Women’s ’ Kids
-------------------------------------------------------------------------------------------------------------------------------------
ANCLOTE KEY ANGLERS
WAIVER AND RELEASE OF LIABILITY
READ BEFORE SIGNING
In consideration of being allowed to participate in any way in the Anclote Key Anglers, athletic sports program, related events and activities, the undersigned acknowledges, appreciates and agrees that:
1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce risk, the risk for serious injury does exist, and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation, and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however, I observe any unusual, significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately, and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Anclote Key Anglers and their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“RELEASES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP ALL SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT AND INDUCEMENT.
Name: _________________________________________ Date: _________________
Signed: (Participants Signature) __________________________________________
FOR PARTICIPANTS OF MINORITY AGE 5+
(UNDER 18 AT THE TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the releases from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES, to the fullest extent permitted by law.
Minor participant Name:________________________________________________
Signed _________________________________ Date Signed ___________________
(Parent/ Guardian Signature)
Emergency Phone number(s): _________________________________________
|