Name:                                                                      Date of Birth:                                                  

Address:                                                                                                                                         

Phone(s):                                                              Tournament Location:                                          

Fishing Option (circle one):        Boater        Boat & Family Member        No Boat        New Member

I, the undersigned, do hereby release and discharge the BLOOMINGTON NORMAL BASS CLUB, INC., a not-for-profit corporation, from any loss or damage to me or my property as a result of any casualty, loss, damage or injury of any nature, which might occur directly or indirectly as a result of my participation in the Club sponsored activity described on this form.  I agree not to sue, claim or demand reimbursement against the club or its agents for it’s conduct of the activity described on this form.  I agree to hold harmless and indemnify the Club for any claim made by anyone on my behalf against the Club or by agent, heirs, executors or assigns as a result of the Club activity.

Dated this                day of,                     .

Signature:                                                                      Date:                                                             

** $300,000 in liability insurance is required on all boats used in BNBC tournaments.